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College  of  ^tipsitctansi  anti  ^urseonsf 


librarp 


UROLOGY 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/urologydiseasesoOOkeye 


PLATE    I 


B.  S.  Barringer. 


•I  >.A-. 


PLATE  I 

Ctstoscopic  Views  of  Various  Abnormal  Conditions  Within  the  Bladder. 

Fig.  1. — Cystocele.     The  ureter  orifice  is  in  a  depression.     All  trigonal  landmarks  lost. 
Fig.  2. — Stone  of  uric  acid  covered  with  xanthin  (which  could  not  be  radiographed)  lying 

near  the  ureter  orifice. 
Fig.  3. — Orifice  of  a  saccule  in  a  chronically  inflamed  and  trabeculated  bladder. 
Fig.  4. — Depression  of  the  fundus  by  extravesical  carcinoma  (of  uterus) ;  cystitis. 
Fig.  5. — Invasion  of  bladder  wall  by  uterine  carcinoma ;  no  cystitis. 
Fig.  6. — Carcinoma  of  both  lateral  lobes  of  a  hypertrophied  prostate. 
Fig.  7. — Diverticulum  produced  by  adhesion  of  the  bladder  wall  to  uterine  carcinoma. 
Figs.  8  and  9. — Right  and  left  ureters  of  a  patient  with  left  renal  tuberculosis  of  seven  years' 

duration.     The  right  ureter  (Fig.  8)  is  normal ;  the  trigone  and  bladder  wall  on  the  edge 

of  the  field  are  congested.     The  left  ureter  (Fig.  9)  is  only  slightly  deformed  and  the 

surrounding  area  is  congested. 
Fig.  10. — Tuberculous  ulceration  of  ureter  orifice. 
Fig.  11. — The  same,  six  weeks  after  nephrectomy. 
Fig.  12. — Tuberculous  ulceration  of  ureter  orifice. 
Fig.  13. — Varicose  veins  of  the  bladder. 
Fig.  14. — Intravesical  ureteral  cyst. 
Fig.  15. — Papilloma  growing  near  the  ureter  orifice.     It  is  ulcerated  and  a  long,  narrow 

clot  of  blood  is  adherent  to  it. 


UROLOGY 

DISEASES  OF  THE  URINARY  ORGANS 

DISEASES  OF  THE  MALE 
GENITAL  ORGANS 

THE  VENEREAL  DISEASES 


BY 

EDWARD   L.  KEYES,  Jr.-  M.D.,  Ph.D. 

pbofessok  of  urology,  cornell  ttniversitr  medical 

college;    surgeon  to  st.  Vincent's,  and 

urologist  to  bellevue  hospital 


WITH  TWO  HUNDRED  AND  FOUR  H^LUSTRATIONS  IN  THE  TEXT  AND 
EIGHTEEN  PLATES,  FOUR  OF  WHICH  ARE  COLORED 


NEW    YORK    AND    LONDON 
D.    APPLETON    AND     COMPANY 

1921 


1  rii 


Copyright,  1917,  by 
D.  APPLETON  AND  COMPANY 


^ '-  -^  T  \ 


Vx 


Van  Buren  and  Kbtes'  Text-Book 

Copyright,  1874,  1888,  by  D.  Appleton  and  Company 

The  Sukgical  Diseases  op  the  Genito-Urinart  Organs,  including  Syphilis 
Copyright,  1892,  1900,  by  D.  Appleton  and  Company 

The  Surgical  Diseases  of  the  Genito-Urinary  Organs 
Copyright,  1903,  1905,  by  D.  Appleton  and  Company 

Diseases  op  the  Genito-Urinary  Organs 

Copyright,  1910,  1911,  1913,  by  D.  Applefon  and  Company 


Printed  in  the  United  States  of  America 


TO 

MY  BELOVED   FATHER 

THIS    BOOK   IS   AFFECTIONATELY 
DEDICATED 


PREFACE 

The  advance  of  Urology  in  the  past  decade  has  quite  destroyed 
the  value  of  the  volume  of  which  this  is  the  successor.  ISTot  only  have 
the  sections  devoted  to  Cystoscopy,  Radiography,  Renal  Tunction 
Tests,  Renal  Infections  and  Tuberculosis  been  rewritten  throughout, 
but  the  viewpoint  from  which  we  now  regard  Gonorrhea,  Prostatism, 
Syphilis  and  many  of  the  Operations  upon  the  Urinary  Organs  has  so 
changed  that  those  sections  also  have  been  radically  altered.  Indeed 
excepting  only  those  chapters  descriptive  of  the  early  lesions  of 
Syphilis  not  a  single  page  of  the  older  work  but  has  suffered  some 
change — we  hope  for  the  better.  The  general  scheme  of  the  volume 
remains  the  same,  though  some  of  the  chapters  have  been  rearranged 
for  greater  clarity  of  presentation,  and  Syphilis,  which  does  not  prop- 
erly belong  to  Urology,  has  been  relegated  to  an  appendix. 

The  present  volume  is  founded  much  more  on  personal  clinical 
and  pathological  experience  than  its  predecessor,  and  while  the  work 
of  others  has  been  freely  quoted,  it  has  seemed  essential  for  unity  of 
presentation  that  much  purely  statistical  material  be  simply  referred 
to  in  footnotes. 

More  than  fifty  illustrations  have  been  added,  about  half  of  these 
being  radiographs  for  the  greater  number  of  which  we  are  indebted 
to  Dr.  Byron  C.  Darling;  for  a  minority  to  Dr.  E.  W.  Caldwell  and 
Dr.  L.  G.  Cole.  Gratitude  is  also  due  to  Dr.  B.  S.  Barringer  for 
assistance  in  many  ways,  and  to  Dr.  E.  D.  Barringer,  whose  chapters 
on  Gonorrhea  in  the  Female  have  been  retained.  To  the  laboratory 
staff  of  Cornell  University  Medical  College  is  due  whatever  scientific 
sanity  this  book  exhibits.  Its  errors,  in  science  as  well  as  clinical 
matter,  may  be  imputed  only  to  the  author. 

Edwaed  L.  Keyes,  Jk. 
!N^ew  York. 


CONTENTS 


THE  PEINCIPLES  OF  UROLOGY 

CHAPTER 

I. — Physical  Examination 
II. — Urinalysis         ..... 
III. — Urethral  Instruments  :  Their  Asepsis 
IV. — The  Passage  of  Urethral  Instruments 
V. — Cystoscopy        .         .         .         . 
VI. — Cystoscopy  of  the  Diseased  Bladder 
VII. — Ureter  Catheterism 
VIII. — Estimation  of  the  Eenal  Function  . 
IX. — Radiography      ..... 


GONOERHEA 


X. — Gonorrhea:  Its  Social  Aspects  and  Prevention  . 
XI. — The  Gonococcus         ........ 

XII. — Gonorrhea:  The  Extragenital  Types  of  Inoculation;  The  Sys 
temic  Manifestations         ...... 

XIII. — Ocular  Gonorrhea    ........ 

XIV. — Gonorrheal  Vulvovaginitis  in  Children    .         .         .         . 

XV. — Gonorrhea  in  Women         ....... 

XVI. — Gonorrheal  Urethritis  in  the  Male         .... 

XVII. — Symptoms,  Course  and  Complications  of  Acute  Urethral  Gon 
orrhea  in  the  Male  ....... 

XVIII. — Course  and  Complications  of  Chronic  Urethral  Gonorrhea 
XIX. — Nongonorrheal  Urethritis       ...... 

XX. — Diagnosis  of  Gonorrheal  Urethritis         .... 

XXI. — Urethroscopy    ......... 

XXII. — Methods  and  Drugs  Employed  for  the  Local  Treatment  of 
Urethritis  ........ 

XXIII. — Systemic  Treatment  of  Urethral  Gonorrhea  . 

XXIV. — Local  Treatment  of  Acute  Gonorrhea      .... 

XXV. — Local  Treatment  of  Chronic  Urethritis  .... 


DISEASES  OF  THE  URINARY  ORGANS 


XXVI. — Spasmodic  and  Congenital  Stricture 
XXVII. — Organic  Stricture  of  the  Urethra — Etiology,  Pathology,  Symp- 
toms, Eesults,  Diagnosis  .  ,      . 
XXVIII. — Stricture  of  the  Urethra;  Prognosis  and  Treatment 
XXIX.— ^The  Prostate:  Anatomy,  Physiology — Prostatism  . 
XXX. — Symptoms,  Diagnosis  and  Prognosis  of  Prostatism   . 
XXXI. —  Treatment  of  Prostatism  ..... 

XXXII. — Malignant   Neoplasms   of   the  Prostate — Neoplasms   of   the 

Urethra 311 

iz 


X  CONTENTS 

CHAPTEE           "  PA6B 

XXXIII. — Etiology  of  Infection  of  the  Upper  Urinary  Tract  .         .         .  318 

XXXIV. —  Pathology  of  Eenal  Infection         ......  331 

XXXV. —  The  Clinical  Picture  of  Eenal  Infection         ....  339 

XXXVI. — Diagnosis  of  Eenal  Infection 352 

XXXVII.— Treatment  of  Eenal  Infection           ,          .          .          .          .          .  355 

XXXVIII.-4]ystitis    .          .         • 364 

XXXIX.-/tjRixARY    Calculus:     Varieties — Etiology — Treatment    Other 

than  Eadical     .........  375 

XL. — Eenal  and  Ureteral  Calculus  .......  382 

XLI. —  Calculi  and  Foreign  Bodies  of  Bladder  and  Urethra         .          .  403 

XLII. — Genito-urinary  Tuberculosis    .......  414 

XLIII. —  Tuberculosis  of  the  Kidney     .......  416 

XTilV. — Tuberculosis  and  Simple  Ulceration  of  the  Bladder — Tubercu- 
losis OF  THE  Prostate  and  Seminal  Vesicles        .          .          .  432 
XLV. —  Movable  Kidney       .........  441 

XLVI. —  The  Ureters  and  Their  Diseases     ......  451 

XLVII. — Hydronephrosis          .........  456 

XLVIII. —  Physiology  and  Various  Diseases  of  the  Bladder     .         .         .  465 

XLIX. —  Diseases  Peculiar  to  the  Female  Bladder       ....  474 

L. —  Idiopathic  Eenal  Hematuria — ^Varicose  Veins  of  the  Bladder  478 

LI. —  Cysts  and  Tumors  op  the  Kidney   ......  481 

LIT.-^  Tumors  of  the  Bladder  and  Urethra       .....  495 

LIII. — Injuries  to  the  Kidney  and  Ureter — Aneurysm  of  the  Eenal 

Artery        ....'......  511 

LrV. —  Wounds  and  Euptures  of  the  Bladder  and  Urethra  .          .          .  520 

LV. —  Malformations  of  the  Kidney  and  Ureter        ....  530 

LVI, —  Malformations  of  the  Bladder  and  Urethra    ....  538 

DISEASES  OF  THE  GENITAL  OEGANS 

LVII. —  Diseases  of  the  Scrotum  ........  549 

LVIII. —  Anatomy,    Physiology,    Embryology,    and    Anomalies    of    the 

Testicle      ..........  557 

LIX. — InTj'lammations  of  the  Testicle  and  Epididymis        .          .          .  566 

LX. —  Tuberculosis  of  the  Epididymis       ......  580 

LXI. — .  Dis^^ES  OF  THE  Testicle  ........  588 

LXII. —  Hy-]5rocele,  Hematocele,  Spermatocele,  Chylocele    .         .         ,  598 

LXIII. — Disea£:es  of  the  Vas  Deferens  and  Spermatic  Cord  .          .          .  610 

LXrV. — Diseases  of  the  Seminal  Vesicle     ......  616 

LXV. —  Derangements  of  the  Genital  Function  .....  621 

LXVI. —  Diseases  of  the  Penis — Anatomy — Injuries — Inflammations    .  637 

LXVII. —  Phimosis — Paraphimosis — Tumors  of  the  Penis        .         .         .  649 

LXVIIL— Chancroid 660 

OPEEATIVE  SUKGEEY 

LXIX. —  General  Considerations  in  Operating  on  the  Urinary  Organs  668 

LXX. —  Operations  Upon  the  Kidney  .......  677 


LXXI. —  Operations  Upon  the  Kidney  (Continued) 
LXXII. —  Operations  Upon  the  LTreters  .... 
LXXIII. — ■  Anatomy  of  the  Bladder — Suprapubic  Operations 
LXXIV. —  Median   Perineal  Section         .... 
LXXV. —  Operations  Upon  the  Prostate  and  Seminal  Vesicles 


688 
700 
710 
725 
736 


CONTENTS  xi 

CHAPTER  PAGE 

LXXVI. —  Intravesical  Operations  .         .         .         .         .         ,         .         .  752 

LXXVII. —  Operations  for  the  Cure  of  Urinary  Fistula  ....  761 

LXXVIII. — Operations  for  Malformations  op  the  Urethra  and  Bladder     .  7G7 

LXXIX. —  Operations  Upon  the  Scrotum  and  Its  Contents     .         .         .  77.'J 

LXXX. —  Operations  Upon  the  Penis     .......  786 


APPENDIX 


SYPHILIS 


LXXXI. — The  General  Characteristics  of  Syphilis         ....  793 

LXXXII. —  Etiology,  Serology  and  Pathology  of  Syphilis         .         .  802 

IjXXXIII. — The  Course  of  Syphilis .  814 

LXXXIV. — Diagnosis  of  Syphilis 821 

LXXXV. — Treatment  of  Syphilis     ........  823 

LXXXVL— The  Initial  Lesion 839 

LXXXVII. — Syphilis  of   the  Skin:    General   Characteristics;   Secondary 

Syphilids — Secondary  Syphilis  of  the  Mucous  Membrane  .  846 

LXXXVIII. — Tertiary  Syphilids  of  the  Skin  and  Upper  Respiratory  Tract  856 
LXXXIX. —  Syphilis  of  the  Nervous  System,  The  Eye,  the  Bones,  the 

Viscera  and  Other  Regions         .         .         .         .         .         .  863 

XC. — Hereditary  Syphilis  ........  873 


INDEX 


889 


LIST  OF  PLATES 


FACING 
PAGE 

Abnormal  Conditions  Within  the 


I.  Cystoscopic  Views  of  Various 

Bladder  ......... 

II,  Cystoscopic  Interpretation  of  the  Appearance   of  the 

Neck  in  Prostatism         ....... 

III.  Eadiograms  of  Prostatic  Calculi  and  Calcified  Iliac  Arteries 

IV.  Pyelography  in  the  Diagnosis  of  Ureteral  Calculus 

V.  Pyelography  in  the  Diagnosis  of  Ureteral  Calculus 

VI.  Bilateral  Silent  Eenal  Calculi    .... 

VII.  Radiograms  of  Gall-stones    ..... 

VIII.  Pyelography  in  the  Diagnosis  of  Ureteral  Calculus 

IX,  Microphotographs  of  Gonococci  and  Tubercle  Bacilli 

X.  The  Usual  Type  of  Prostatism     , 

XI,  Focal  Suppuratave  Nephritis 

XII,  The  Tongue  of  Urinary  Septicemia 

XIII,  The  Urine  of  Pyonephrosis  , 

XIV.  Eenal  Tuberculosis 
XV.  Eenal  Tuberculosis 

XVI.  Eadiograms  of  Eenal  Tuberculosis  and  Hydronephrosis 

XVII.  Pyelogram  of  Hydronephrosis       ..... 

XVIII.  Stereoscopic  Cystography  op  Diverticula 


Frontispiece 
Bladder 

62 


90 

92 

94 

96 

98 

110 

286 

332 

344 

354 

416 

418 

428 

462 

542 


LIST  OF  ILLUSTRATIONS  IN  TEXT 


FIGtJRH  PAGE 

1. — Double  taper   sound      ..........  21 

2. — Olivary  bougie     ...........  21 

3. — Bulbous  bougie    ...........  21 

4. — Kollmann  dilators         ..........  21 

5. — Whalebone  filiform  and  tunneled  sound  .......  22 

6. — Woven  filiform  and  Janet  sound  .  .  .  .  .  .  .  .22 

7. — Woven  olivary  catheters        .........  23 

8. — Double-elbowed  catheter       ...*.....  23 

9. — Natural  curve  catheter           .........  24 

10, — Guyon   obturator           ..........  24 

11. — Janet  syringe       ...........  25 

12. — Keyes  instillator  .  .  .  ,  .  .  .  .  .  .26 

13. — Sagittal  section  through  glass  and  fossa  navicularis         ....  32 

14. — Transverse  section  of  the  penis     ..,....,  32 

15, — Lacuna  magna,    ...........  33 

16. — Lower  part  of  the  male  bladder  with  the  beginning  of  the  urethra  .          ,  35 

17, — Sagittal  section  of  a  frozen  male  subject      ......  36 

18. — Longitudinal  section  of  urethra     .........  37 

xiii 


right 


kidney 


xiv  LIST  OF  ILLUSTRATIONS  IN  TEXT 

FIGURE 

19.— Introduction  of  sound  . 

20. — Introduction  of  sound  . 

21. — Introduction  of  sound.  . 

22. — The  Brown-Buerger  cystoseope 

23. — Lenses  of  prismatic  cystoseope 

24. — Lenses  of  direct  vision  cystoseope 

25. — Flute-tipped  catheter    . 

26. — Maneuvers  in  catheterizing  right  ureter 

27. — Radiogram  showing  bladder  and  prostatic  calculi 

28. — Vesical  calculus:  phlebolith  in  region  of  pelvic  ureter 

29. — Vesical  calculi 

30. — The  stone-bearing  area 

31.— Phleboliths 

32. — Calculus  in  seminal  vesicle 

33. — Numerous  small  oxalate  calculi  in  lower  calyces  of 

34. — Eenal  calculi        .... 

35. — Silent  calculus  filling  the  renal  pelvis 

36. — Normal  kidney  pelvis    (pyelogram) 

37. — Normal  kidney  pelvis   (pyelogram) 

38. — Damage  done  by  pyelography 

39. — Damage  done  by  pyelography 

40. — Chetwood  irrigation.     Filling  the  nozzle 

41. — Chetwood  irrigation.     Inserting  the  nozzle 

42. — Tip  of  instillator  in  bulbous  urethra 

43. — Tip  of  instillator  in  posterior  urethra 

44. — Chetwood 's  tube  for  rectal  irrigation 

45. — Injection  of  urethral  fistula  . 

46. — Congenital  stricture  of  the  meatus 

47. — Stricture  of  anterior  urethra 

48. — Stricture  of  membranous  urethra 

49. — Eesults  of  stricture 

50. — False  passage 

51. — Introduction  of  filiforms 

52. — Sagittal  section  of  prostate,  bladder  neck  and  membranous  urethra 

53. — Adenoma  enucleated  from  prostate         ..... 

54. — Section  of  a  large  prostatic  adenoma,  showing  its  composite  character 

55. — Prostatism;  transverse  section  showing  enlargement  of  lateral  lobes 

56. — Bilateral  prostatic  enlargement 

57. — General  sclerosis  of  the  prostate 

58. — General  enlargement  of  the  prostate  with  median  bar 

59. — Pedunculated  median  enlargement 

60. — Sagittal  section  of  Fig.  56   . 

61. — Sagittal  section  of  Fig.  57  . 

62. — Sagittal  section  of  Fig.  58   .  . 

63. — Sagittal  section  of  Fig.  59  . 

64. — Section  of  enlarged  prostate 

65. — Section  of  normal  prostate   . 

66. — Sagittal  section  of  prostate,  illustrating  origin  of 

67. — Focal  suppurative  nephritis 

68. — Pyonephrosis 

69. — Perinepliritis 

70. — Cystitis  cystica  adjacent  to  a  carcinoma  of  the  bladder 

71. — Section  of  a  pliosphatic  calculus,  showing  excentric  development 


carcinoma 


LIST  OF  ILLUSTRATIONS  IN  TEXT 

FIGUEB 

72. — Uric  acid  calculus  (section)  ........ 

73. — Section  of  calculus  of  mixed  uric  acid  and  oxalate  of  lime,  coated  with 
phosphates   ....... 

74. — Multiple  phosphatic  calculi   (natural  size) 

75. — Oxalate    (mulberry)    calculus  .... 

76. — Multiple  small  phosphatic  calculi  (natural  size) 
77. — Large  branched  renal  calculus      .... 

78. — Kidney  destroyed  by  large  branching  silent  calculus 

79. — Calculous  anuria ;  the  congested  kidney  . 

80. — Calculous  hydronephrosis       ..... 

81. — Calculous  pyonephrosis  ..... 

82. — ^Pyelogram  showing  dilated  kidney  and  ureter   (pyelonephritis)   after  re- 
moval of  stone     ...... 

83. — Large  renal  calculi       ...... 

84. — Silent  vesical  calculi     ...... 

85. — Stone  on  twig       ....... 

86. — Stones  formed  on  hairs  of  a,  dermoid  cyst  ruptured  into  the  bladder 

87. — Eenal  tuberculosis        ...... 

88. — Eenal  tuberculosis        ...... 

89. — Eenal  tuberculosis        ...... 

90. — Eenal  tuberculosis        ...... 

91. — Eenal  tuberculosis        ...... 

92. — Eenal  tuberculosis         ...... 

93. — Eenal  tuberculosis        .  .  .  .  .  . 

94. — Pyelogram  of  Fig.  93  .  .  .  .  . 

95. — Pyelogram  of  Fig.  96  . 

96. — Eenal  tuberculosis  (and  gonorrhea)  after  pyelography 

97. — Movable  kidney  injected  with  argyrol    . 

98. — Hydronephrosis  from  ureteral  compression  by  a  branch  of  the  renal 

99. — Polycystic  kidney  ...... 

100. — Outline  of  polycystic  kidney  and  spleen 

101. — Adenocarcinoma  of  the  hypernephroma  type  . 

102. — Carcinoma  of  the  kidney       ..... 

103. — Sarcoma  of  kidney  invading  the  vena  cava     . 
104. — Papilloma  of  bladder  ...... 

105. — Carcinoma  of  the  bladder      ..... 

106. — Papillary  carcinoma     ...... 

107. — Lobulated  carcinoma    ...... 

108. — Carcinomatous  infiltration  beneath  apparently  normal  mucosa 
109. — Euptured  kidney  ...... 

110. — Congenital  kidney  atrophy;  stone  in  pelvis;  pyelitis  cysti 
111. — Horseshoe  kidney  ...... 

112. — Urinal  for  exstrophy   ...... 

113. — Sacculated  bladder       ...... 

114. — Cystography  showing  diverticulum 

115. — Cystography  showing  large  phlebolith  near  bladder  . 

116. — Pediculus     ........ 

117. — Epithelioma  of  the  scrotum  in  a  paraflBn  worker 
118. — Scrotal  epithelioma       ...... 

119. — Left  tunica  vaginalis  opened,  showing  testis,  epididymis,  etc.,  from  outer 
side      ........ 

120. — Abscess  in  tail  of  epididymis;  relapsing  epididymitis 
121. — Eubber  bandage  for  strapping      .... 


XV 

PAGE 

375 


376 
376 
377 
377 
382 
384 
389 
390 
390 

391 

403 

405 

408 

409 

417 

417 

418 

419 

421 

422 

426 

427 

428 

429 

447 

457 

482 

483 

487 

488 

490 

497 

498 

498 

498 

507 

512 

532 

534 

539 

539 

540 

542 

551 

555 

556 

557 
571 
576 


and 


glans 


penis 


in  various 


stages 


posterior  view 


xvi  LIST  OF  ILLUSTRATIONS  IN  TEXT 

FIGURE  p^ej, 

122. — The  bandage  applied    ..........     576 

123. — Specimens  obtained  by  orchideetomy  and  epididyniectomy  for  tuberculosis  582 

124. — Section  of  tuberculous  testicle 

125. — Carcinoma  of  testicle    . 

126. — Usual  form  of  hydrocele 

127. — Eadiogram  of  calcified  tunica  vaginalis 

128.— Hydrocele 

129. — Congenital  hydrocele     . 

130. — Infantile  hydrocele 

131. — Hematocele  .  ... 

132. — Seminal  vesicles  .... 

133. — Transverse  sections  of  penis 

134. — Paraphimosis        .... 

135. — Paraphimosis        .... 

136. — Eeduction  of  paraphimosis  . 

137. — Epithelioma  of  the  penis 

138. — Streptobacillus  of  Ducrey     . 

139. — Chancroids  of  prepuce,  preputial  frenum, 

of  development 
140. — Pezzer   self-retaining  catheter 
141. — Filiform  bougie  tied  on 

142. — Sinclair's  method  of  fixing  retained  catheter 
143. — Frontal  section  through  the  kidney,  pelvis  and  calices 
144. — Diagram  showing  relation  of  the  viscera  to  the  parietes; 
145. — Situation,  direction,  form  and  relations  of  the  kidneys 
146. — ^Patient  lying  on  side,  showing  proximity  of  free  border 

ilium    ........ 

147. — Patient  as  in  Fig  146,  but  elevated  by  ' '  kidney  support ' 

148.- — The  oblique  "kidney"  incision 

149. — Nephrotomy  incision     . 

150. — Nephrotomy  with  decapsulation     . 

151. — Restricted  liberation  of  perirenal  fat  in  nephrostomy  for 

152. — Nephrectomy         .  .  . 

153. — Showing  how  the  true  pedicle  is  obscured  by  the 

capsular  nephrectomy    .... 

154. — IJ  reteroplasty        ...... 

155.— Ureteroplasty        ...... 

156. —  Ureteroplasty        ...... 

157. — End-in-end  anastomosis  of  ureter  . 

158. — Oblique  end-to-end  anastomosis  of  ureter 

159. — Lateral  anastomosis  of  ureter 

160. — Lateral  anastomosis  of  ureter 

161. — Uretero-intestinal   anastomosis 

162. — Exposure  of  the  bladder        .... 

163. — Incision  of  the  bladder  .... 

164. — Inversion  of  bladder  wall  about  tube     . 
165. — Lithotomy  forceps         ..... 

166. — Permanent  suprapubic  drainage  tube 

167. — Perineal  tube       ...... 

168. — Median  perineal  section  under  local  anesthesia 
169. — Maisonneuve  urethrotome      .... 

170. — Otis  urethrotome  ..... 

171. — Perineal  incisions  ..... 


of  ribs 


to  crest  of 


pyonephrosis 
fibrous  capsule  in  sub- 


LIST  OF  ILLUSTRATIONS  IN  TEXT 

PIGDRE 

172. — Chetwood's  prostatic  incisor 

173. — Chetwood  's  perineal  galvanoprostatotomy 

174. — Young's  prostatic  punch 

175. — Bigelow   lithotrite         .... 

176. — Keyes  lithotrite   ..... 

177. — Bigelow  aspirator  and  washing-tube 

178. — Showing  the  manner  of  holding  the  lithotrite  when  opening  and 

the  search  for  fragments 
179. — Showing  the  manner  of  holding  the  bulb 
180. — Operating  cystoscope  .... 
181. — Cystoseopic  forceps  .... 
182. — Tuberculous  fistula  following  nephrectomy 
183. — Beck's  operation  for  balanitic  hypospadias 
184. — Beck's  operation  for  balanitic  hypospadias 
185. — Beck's  operation  for  balanitic  hypospadias 
186. — fiochet's  modified  Nove-Josserand  operation  for  hypospadias 
187. — Eochet's  modified  Nove-Josserand  operation  for  hypospadias 
188. — Tapping  for  hydrocele  .... 
189. — Method  of  applying  circumcision  forceps 
190. — Dressing  after  circumcision  . 
191. — Spirochaeta  pallida   (two  in  center)   and  refringens  (three, 

stained)        ....... 

192. — Large  ulcerated  hunterian  chancre 

193. — Macular   syphilids         ...... 

194. — Papular  syphilid;  confluent  on  face 

195. — Syphilitic  alopecia        ...... 

196. — Circinate  papulosquamous  syphilid  on  forearm 
197. — Squamous  syphilid  of  palm  ..... 

198. — Confluent  tubercular  syphilid  of  nose     . 
199. — Serpiginous  tuberculo-ulcerative  syphilid 
200. — Gummatous  ulcer,  tibial  node         .... 

201. — Saber  tibia  of  hereditary  syphilis  .... 

202. — Gumma  of  inner  condyle  of  femur  and  outer  condyle 

tary  syphilis)  ;    arthritis         .... 

203.— Syphilitic   nose    ....... 

204, — Pezzer  self-retaining  catheter       .         .         »         . 


shutting  in 


deeply 


of  tibia   (heredi 


XVll 
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802 
841 
849 
850 
851 
852 
852 
857 
858 
859 
867 

868 
877 
885 


UROLOGY 

CHAPTER   1 
PHYSICAL  EXAMINATION 

The  physical  examination  of  a  patient  cannot  be  too  thorough: 
errors  in  diagnosis  are  more  often  due  to  incomplete  or  careless  physical 
examination  than  to  any  other  fault.  There  are  in  the  United  States 
today  innumerable  victims  of  renal  stone  and  tuberculosis  being  treated 
for  an  imaginary  cystitis.  Twice  I  have  seen  prostatectomy  done  for 
pyelonephritis.  Once  I  have  seen  a  testis  removed  for  syphilis  and 
twice  for  subacute  epididymitis,  the  diagnosis  of  tuberculosis  having 
been  erroneously  made  in  each  instance.  Several  patients  suffering 
from  arteriosclerotic  nocturnal  polyuria  have  been  referred  to  me  for 
prostatectomy.  I  know  of  a  patient  who  submitted  for  months  to 
vigorous  local  treatment  for  a  mild  gleet  while  he  was  dying  of  chronic 
nephritis. 

Such  gross  errors  are  due  to  careless  physical  examinations.  Yet  it 
would  be  hard  to  decide  precisely  what  constitutes  a  complete  and  care- 
ful examination.  It  is  certainly  improper,  for  example,  to  cystoscope 
every  patient  with  gonorrhea ;  yet  it  is  eminently  essential  for  some 
of  them.     ' 

The  expert  diagTiostician  shows  his  skill  not  only  by  basing  his 
diag-nosis  on  the  salient  points  in  the  history  and  physical  examination, 
but  also  and  above  all  by  recognizing  the  doubtful  cases  and  exhausting 
for  them  every  means  of  diagnosis  at  his  command. 

The  general  rule  of  physical  diagnosis  should  therefore  be  this: 
Examine  the  patient  to  obtain  a  thorough  knowledge  not  only  of  the 
disease  from  which  he  suffers  but  also  of  all  possible  complications  and 
concomitant  maladies  that  may  have  a  bearing  upon  the  prognosis  or 
the  treatment  of  this  disease. 

Disease  of  the  urinary  organs  is  peculiarly  prone  to  be  complex. 
That  a  patient  has  prostatitis  is  no  evidence  that  he  has  not  pyelone- 
phritis. That  he  has  a  stone  in  his  bladder  does  not  prove  that  he  has 
not  another  in  his  ureter.  That  he  has  a  tubercular  prostate  does  not 
guarantee  him  against  renal  tuberculosis.  These  are  but  gross  exam- 
ples of  the  fact  that  we  i^iust  be  constantly  on  our  guard  against  com- 

1 


2  PHYSICAL  EXAMINATION 

plex  conditions  in  the  genito-urinary  tract  of  which  the  more  obvious 
lesion  may  be  the  less  important. 

The  detail  of  our  physical  examination  should  cover  several  fields, 
fiz. : 

General  Physical  Examination. 

Urinalysis. 

External  Examination  of  the  Genito-urinary  Tract. 

Internal  Examination. 

GENERAL  PHYSICAL  EXAMINATION 

Though  by  no  means  always  essential,  yet  it  is  never  a  waste  of 
time  to  note  the  age,  the  weight,  and  the  circulatory,  pulmonary,  and 
digestive  conditions  of  every  patient.  That  such  observation  is  most 
important  may  be  demonstrated  by  the  following  list  of  conditions  in 
which  data  concerning  the  vital  functions  are  essential : 

The  condition  of  the  circulation  must  be  carefully  studied  in  every 
renal  case.    The  blood  pressure  is  especially  important. 

The  condition  of  the  lungs  is  preeminently  important  in  tubercu- 
losis and  in  operative  cases. 

The  condition  of  the  digestion  is  perhaps  the  most  important  of  all. 
It  aifects  the  prognosis  of  even  so  local  a  malady  as  gonorrhea.  It 
determines  the  dosage  of  sandalwood  oil  as  well  as  of  hexamethylen- 
amin.    It  enters  into  the  diagnosis  of  certain  forms  of  urinary  toxemia. 

Study  of  such  important  factors  is  therefore  not  time  wasted.  Yet 
the  detail  of  such  study  is  no  special  province  of  ours :  it  belongs  to  the 
general  education  of  every  qualified  practitioner. 

URINALYSIS 

Urinalysis,  too,  belongs  to  general  medicine.  Yet  certain  features 
of  it  are  of  such  special  importance  in  disease  of  the  genito-urinary 
organs  that  they  merit  detailed  consideration  in  Chapter  11. 

EXTERNAL  EXAMINATION  OF  THE  GENITO-URINARY  TRACT 

We  may  consider — 

Palpation  of  the  kidneys  and  ureters. 
^   Palpation  and  percussion  of  the  bladder. 
Rectal  palpation  of  the  prostate  and  seminal  vesicles,  etc. 
Palpation  of  the  penis  and  urethra. 
Palpation  of  the  scrotal  contents. 


EXTERNAL  EXAMINATION  OF  GENITO-URINARY  TRACT        3 
PALPATION  OF    THE    KIDNEYS 

Position  of  the  Patient. — The  patient,  with  back  and  abdomen 
bared,  lies  upon  his  back  with  his  knees  drawn  up  and  his  hands  at  his 
sides,  so  as  to  relax  the  abdominal  wall  as  much  as  possible. 

If  examination  in  this  position  proves  unsatisfactory  the  patient 
may  be  turned  upon  the-  side  opposite  to  that  which  is  being  examined. 
Lying  thus  with  knees  well  drawn  up,  the  kidney  is  sometimes  more 
palpable;  but,  as  a  rule,  this  is  not  the  case. 

Palpation  of  the  abdomen  with  the  patient  erect  but  bending 
slightly  forward  may  reveal  renal  mobility  that  otherwise  escapes  ob- 
servation. But  many  patients  cannot  relax  the  abdominal  muscles 
while  in  this  position,  which  is  therefore  but  little  employed. 

Position  of  the  Examiner — The  examiner  sits  or  stands  next  to  the 
side  to  be  examined. 

The  Operation — If  the  kidney  is  very  large  its  outlines  may  be  de- 
termined by  abdominal  palpation.  Yet  it  is  almost  always  necessary, 
in  order  to  avoid  mistakes,  to  employ  lumho-ahdominal  palpation. 

Lumbo-abdominal  palpation  is  performed  as  follows :  To  examine 
the  rigJit  kidney  the  patient  lies,  as  above  described,  at  the  edge  of  a 
couch,  beside  which,  and  to  the  right  of  the  patient,  the  examiner  sits. 
With  the  index  and  middle  fingers  of  the  left  hand  the  examiner  now 
identifies  and  makes  pressure  upon  the  triangular  depressible  spot  below 
the  last  rib  and  just  at  the  edge  of  the  thick  spinal  muscles.  The  right 
hand  is  then  placed  on  the  anterolateral  abdominal  wall  (about  an 
inch  external  to  the  linea  semilunaris)  with  fingers  directed  upward, 
and  their  tips  just  below  the  free  border  of  the  ribs  (or  of  the  liver  if 
this  be  enlarged).  This  hand  is  pressed  down  as  firmly  as  possible, 
taking  advantage  of  the  relaxation  of  the  parietes  between  inspirations. 

Ballottement. — ^^Vith  the  hands  thus  placed  the  examiner  may 
or  may  not  feel  a  mass  between  them.  In  either  event  he  gives  a  quick, 
sharp  tap  to  the  loin  with  the  fingers  of  the  left  hand.  The  result  of 
this  is  twofold,  viz. : 

1.  It  may  elicit  costovertebral  tenderness.  Deep  tenderness  con- 
fined to  the  region  just  below  the  ribs  and  external  to  the  erector  spinae 
muscles  is  almost  conclusive  evidence  of  inflammation  in  or  about  the 
kidney.    I  have  never  known  myositis  to  cause  tenderness  in  this  region. 

2.  It  may  elicit  renal  ballottement.  This  is  the  sensation,  com- 
parable to  fetal  ballottement,  imparted  to  the  fingers  depressing  the 
anterior  parietes  when  a  sharp  tap  from  behind  throws  an  intra-abdom- 
inal body  against  them. 

Ballottement  should  be  attempted  first  during  normal  respiration, 
then  with  the  patient  breathing  deeply,  just  as  the  abdominal  wall 
relaxes  at  the  end  of  the  inspiratory  efl'ort. 


i  PHYSICAL  EXAMINATION 

Renal  ballottemerit  discloses  the  presence  of  a  movable  mass  in  the 
loin.  It  does  not  prove  that  mass  to  be  a  kidney,  nor,  if  kidney  it  be, 
that  the  organ  is  diseased.  One  may  obtain  ballottement  from  a  mass 
of  tubercular  glands  and  from  a  neoplasm  or  "corset  lobe"  of  the  liver. 

Yet  as  a  clinical  sign  ballottement  is  most  useful.  When  the  kidney 
is  normal  in  size  and  position  ballottement  can  be  obtained  only  if  the 
patient  is  very  thin  and  the  abdomen  very  lax. .  But  when  the  organ  is 
abnormal  in  size  or  mobility  and  this  abnormality  is  but  slight,  or  when 
examination  is  impeded  by  fat  or  rigidity,  ballottement  may  be  the  only 
clinical  evidence  of  this  change. 

Thus  ballottement  of  the  kidney  reveals  slight  enlargement  or  mobil- 
ity, though  other  signs  must  be  depended  upon  to  prove  that  the  mass 
felt  actually  is  kidney. 

Palpation. — In  many  instances  the  mass,  while  large  enough  to  be 
felt  very  distinctly  by  ballottement,  escapes  every  other  method  of 
lumbo-abdominal  palpation  except  the  following:  The  patient  is  in^ 
structed  to  take  repeated  deep  breaths,  and  as  he  does  so  the  examiner 
gradually  insinuates  the  fingers  of  his  right  hand  deeper  and  deeper 
under  the  ribs,  until,  at  a  propitious  moment  of  post-inspiratory  relaxa- 
tion, rather  sudden  and  sustained  bimanual  pressure  distinctly  catches 
the  lower  pole  of  the  kidney  before  it  slips  back  under  the  ribs. 

Considerable  enlargement  or  mobility  of  the  kidney  is  better  studied 
by  simple  bimanual  palpation.  The  mass  is  readily  felt  between  the 
hand  on  the  loin  and  the  hand  on  the  abdomen,  and  palpation  and  per- 
cussion are  employed  to  outline  its  shape,  size,  and  mobility. 

Pekcussion. — A  dull  or  flat  percussion  note  is  obtained  over  the 
kidneys.  But  the  presence  of  the  liver  and  spleen  immediately  above 
the  kidneys  renders  this  sign  of  little  value. 

Differential  Diagnosis  by  Palpation 

Palpation  of  the  unenlarged  kidney  scarcely  ever  affords  evidence  as 
to  the  exact  nature  of  disease  in  it.  JSTephroptosis  is  diagnosed  by  pal- 
pation (p.  447),  and  a  tender  kidney  is  usually  an  inflamed  kidney. 
Perirenal  exudates  are  sometimes  characteristically  diffuse.  But  with 
these  exceptions  palpation  usually  reveals  little  more  than  the  fact  that 
a  mass  in  the  loin  probably  is  or  is  not  of  renal  origin.  Retroperitoneal 
and  adrenal  growths  cannot  be  distinguished  from  renal  enlargement 
by  palpation. 

The  enlarged  kidney  usually  forms  an  ovoidal  movable  mass,  in 
part  concealed  under  the  ribs,  rising  and  falling  with  respiration,  pal- 
pable by  lumbo-abdominal  palpation  or  ballottement.  But  when  the 
kidney  is  greatly  enlarged,  or  displaced  and  enlarged,  it  may  be  a 
delicate  matter  to  distingiiish  the  resultant  tumor  from  enlargement 


EXTERNAL  EXAMINATION   OF  GENITOURINARY  TRACT        5 

of  liver,  gall-bladder,  spleen,  or  pancreas.  The  kidney  is  more  lateral 
in  position  than  any  of  these  organs  and  more  readily  distinguishable 
by  lumbo-abdominal  palpation. 

Insufflation  of  the  colon  i  may  be  of  use  in  differential  diagnosis. 

On  the  right  side  the  hepatic  flexure  covers  only  the  lower  pole  of 
the  kidney,  but  is  adherent  thereto  (by  the  nephrocolic  ligament  of 
Longyear).  Hence  if  the  kidney  is  greatly  enlarged  it  carries  the 
hepatic  flexure  forward  in  front  of  it,  covering  its  lower  extremity. 
Most  other  growths  reach  the  abdominal  wall  distinctly  above  and  to 
the  inner  side  of  the  angle  of  the  colon  (e.  g.,  gall-bladder,  pancreas, 
pyloiiis),  but  enlargement  of  the  right  lobe  of  the  liver  descends 
external  to  and  in  front  of  it.  Thus  the  only  tumor  whose  lower  end 
is  likely  to  be  covered  by  the  hepatic  flexure  of  the  colon  is  a  renal 
tumor. 

On  the  left  side  the  transverse  colon  crosses  in  front  of  the  lower 
third  of  the  kidney  and  the  descending  colon  lies  external  to  it.  But 
the  lack  of  any  definite  attachment  between  the  two  organs  permits  the 
enlarged  kidney  to  slip  out  from  behind  the  colon.  When  the  left 
kidney  is  sufficiently  large  to  reach  the  abdominal  wall  no  hollow  viscus 
intervenes.  The  descending  colon  borders  the  inner  side  of  the  mass. 
Enlargements  of  the  spleen,  on  the  other  hand,  reach  the  abdominal 
wall  above  the  transverse  colon. 

The  Ureter  Catheter — Inasmuch  as  disease  of  the  kidney  either 
impairs  the  secretion  of  that  organ  or  alters  the  shape  of  its  pelvis 
long  before  it  produces  a  palpable  tumor,  the  main  dependence  in 
diagnosis  is  upon  the  catheterization  of  the  ureters.  A  study  of  the 
urine  thus  obtained,  confirmed  if  necessary  by  pyelography  and  the 
wax-tipped,  catheter,  affords  an  accurate  diagnosis  with  which  the  find- 
ings of  palpation  must  be  made  to  conform. 

PALPATION   OF    THE    URETERS 

The  ureters  lie  upon  the  posterior  abdominal  parietes.  Their  course 
may  be  divided  into  an  abdominal  and  a  pelvic  portion. 

In  the  Abdomen — The  course  of  the  ureter  through  the  abdomen  be- 
gins near  the  outer  edge  of  the  psoas  magnus  muscle  opposite  the  third 
lumbar  vertebra.  Thence  it  runs  on  the  anterior  surface  of  this  muscle 
downward  and  a  little  inward  to  pass  over  the  brim  of  the  pelvis  near 
the  bifurcation  of  the  common  iliac  artery.  At  their  entrance  into  the 
pelvis  the  ureters  are  about  5  cm.  apart. 

The  normal' ureter  cannot  be  palpated  through  the  abdominal  wall. 
Even  when  considerably  enlarged  it  can  only  be  felt  if  the  parietes  be 

^The  apparatus  for  this  operation  is  a  long  rectal  tube  and  the  bulb  of  3 
Paquelin  cautery   (or  an  inverted  Vichy  bottle). 


6  PHYSICAL  EXAMINATION 

thill  and  relaxed.  Points  of  inflammation  in  its  course  may  be  identi- 
fied as  points  of  tenderness.  But  palpation  cannot  distinguisli  ten- 
derness in  the  ureter  from  tenderness  due  to  other  causes.  On  the  right 
side  an  inflamed  ureter  is  likely  to  be  mistaken  for  cholecystitis  or 
appendicitis. 

In  the  Pelvis. — The  ureters  follow  the  lateral  walls  of  the  pelvis  in 
a  wide  curve  whose  convexity  is  outward  and  backward.  As  they  enter 
the  bladder  they  are  about  4  cm.  apart  (though  the  vesical  orifices  are 
separated  by  but  2  cm.). 

Through  the  greater  part  of  their  pelvic  course  the  ureters  are  totally 
impalpable.  Just  as  they  enter  the  bladder  they  become  palpable  in  the 
vaginal  vault  of  the  female,  in  the  anterior  wall  of  the  rectum  in  the 
male.  In  this  location  the  inflamed  ureter  may  sometimes  be  felt  by 
bimanual  (abdominovaginal)  palpation  in  the  female.  It  cannot  be 
felt  by  abdominorectal  examination  in  the  male  unless  very  greatly 
enlarged. 

Vaginal  Palpation. — The  ureter  passes  behind  and  below  the  uterine 
artery  at  a  point  from  0.5  to  1.5  cm.  lateral  to  the  uterine  cervix. 
Thence  its  direction  is  downward,  forward,  and  inward  (almost  trans- 
versely), against  and  adherent  to  the  anterior  vaginal  culdesac,  to  enter 
the  bladder  at  a  point  about  2  cm.  from  the  middle  line  at  the  junction 
of  the  upper  and  middle  third  of  the  vagina. 

Hence  the  sensitive  or  enlarged  ureter  may  be  palpated  for  over 
2  cm.  of  its  course  as  it  runs  transversely  across  the  anterior  vaginal 
culdesac.  As  it  reaches  the  lateral  culdesac  it  is  so  far  distant  from 
the  vagina  (usually  about  1.5  cm.)  as  to  be  inaccessible  unless  greatly 
enlarged. 

Rectal  Palpation. — A  large  ureteral  stone  impacted  at  the  entrance 
of  the  ureter  into  the  male  bladder  may  be  felt  by  rectal  palpation.  It 
may  be  sought  at  a  point  about  1  cm.  above  the  prostate  and  just 
internal  to  the  seminal  vesicle. 

The  Ureter  Catheter. — The  ureter  catheter,  collargol  injection,  and 
the  wax-tipped  catheter  give  the  foundation  of  diagnosis  here,  as  stated 
in  the  preceding  section. 

PALPATION  AND  PERCUSSION  OF  THE  BLADDER 

The  bladder  may  be  examined  by  abdominal  palpation  and  per- 
cussion, by  rectal  palpation,  and  by  recto-abdominal  bimanual  pal- 
pation. 

Abdominal  Palpation  and  Percussion — The  bladder  when  empty  or 
partially  filled  can  neither  be  felt  nor  percussed  through  the  abdominal 
wall.  The  bladder  of  an  infant,  lying  high  in  the  pelvis,  must  contain 
at  least  150  c.c.  before  it  can  be  percussed.     The  bladder  of  an  adult 


EXTERNAL  EXAMINATION  OF  GENITO-URINARY  TRACT        7 

must  contain  300  c.c.  or  more.  To  be  palpable  it  must  contain  about 
1,000  c.c. 

Percussion  of  the  distended  bladder  gives  a  flat  note  over  an  area 
above  the  pubic  bone,  the  dimensions  of  which  depend  upon  the  disten- 
tion of  the  bladder.  This  area  may  extend  but  an  inch  or  two  above  the 
pubes  or  it  may  rise  up  to  or  even  above  the  umbilicus. 

Palpation,  is  only  possible  when  the  bladder  is  distended  at  least  half 
way  to  the  umbilicus.  The  viscus  is  felt  as  a  tense  sphere  rising  from 
the  pelvis. 

When  the  bladder  reaches  the  umbilicus  and  the  abdominal  walls  are 
lax  the  tumor  in  the  hypogastrium  may  be  distinctly  visible. 

Rectal  and  bimanual  palpation. — These  methods  are  described  in 
the  following  section. 

RECTAL  PALPATION:  RECTO -ABDOMINAL  PALPATION 

The  prostate  and,  in  most  instances,  the  seminal  vesicles  may  be  felt 
by  a  finger  introduced  into  the  rectum. 

Peepaeatiox  of  the  Examiner. — The  examiner  may  protect  his 
finger  by  a  simple  lubrication  or  by  a  rubber  glove  or  a  specially  con- 
structed rubber  shield. 

The  best  protector  for  the  finger  is  a  rubber  finger  cot  (a  new  one 
for  each  examination)  and  a  shield  for  the  rest  of  the  hand,  made 
either  by  winding  a  gauze  bandage  about  the  finger  or  by  tearing  a  hole 
in  the  midst  of  a  small  square  of  absorbent  cotton.  The  finger  cot  must 
be  lubricated. 

In  his  other  hand  the  examiner  holds  a  piece  of  gauze  with  which  to 
wipe  the  grease  from  the  patient's  anus  after  the  examination. 

Peeparation  of  the  Patient. — The  patient's  bladder  should  be 
moderately  distended,  preferably  with  boric  acid  solution.  This  is  to 
be  urinated  out  after  the  examination. 

Position  of  the  Patient. — Some  prefer  that  the  patient  should 
be  upon  his  back  with  his  knees  drawn  up,  others  that  he  should  assume 
the  knee-chest  position,  others  that  he  should  bend  over  a  table  with 
his  heels  apart,  his  toes  turned  in,  his  knees  slightly  bent,  his  back 
"swayed." 

Most  patients  can  be  effectively  examined  in  the  position  last  de- 
scribed. With  his  left  hand  upon  the  patient's  left  shoulder  the  exam- 
iner may  exert  counterpressure  to  drive  his  finger  as  far  as  possible  up 
the  rectum.  The  examiner  may  steady  his  right  hand  by  bracing  the 
elbow  against  his  right  knee. 

The  Examination. — As  the  index  finger  is  introduced  with  its  sen- 
sitive pulp  forward  toward  the  anterior  rectal  wall,  it  slips  through  the 
two  sphincters  and  enters  the  rectal  cavity  above. 


8  PHYSICAL  EXAMINATION 

Examination  of  Membranous  Urethra  and  Perineal  Body — ^With 

the  index  finger  hooked  down  and  the  thumb  on  the  patient's  perineum 
an  examination  of  this  body  may  be  made  for  indurations  (cowperitis, 
peri-urethritis).  Just  above  this  the  finger  in  the  rectum  feels  the 
membranous  urethra,  an  almost  imperceptible  cord  about  2  cm.  long, 
in  the  median  line.  Boggy,  lumpy,  or  tender  infiltrations  may  perhaps 
be  felt  about  it. 

Examination  of  the  Prostate. — As  the  membranous  urethra  is  fol- 
lowed up  the  bowel  it  disappears  within  the  apex  of  the  prostate,  which 
is  felt  beneath  the  anterior  rectal  wall. 

The  noiinal  prostate  as  felt 'from  the  rectum  is  heart-shaped,  with 
its  apex  joining  the  membranous  urethra,  its  base  more  or  less  notched 
in  the  center,  its  lateral  lobes  quite  elastic,  its  central  groove  between 
the  two  lobes  more  or  less  marked. 

The  normal  prostate  does  not  project  into  the  rectum.  Its  lateral 
lobes  are  flat  rather  than  bulging.  Its  outline  is  a  little  vagTie.  In 
order  to  examine  it  carefully  the  finger  must  be  swept  over  its  surface 
and  around  its  borders.  Great  experience  is  required  to  recognize  a 
normal  prostate.  So  varied  are  the  degrees  of  sensitiveness  and  of 
prominence  of  the  organ,  so  frequently  do  we  find  phleboliths  or 
enlarged  glands  lying  upon  it  or  near  it,  that  the  specialist  is  fre- 
quently compelled  to  confess  that  he  can  find  nothing  abnormal  in  a 
prostate  that  has  been  pronounced  diseased  by  a  less  experienced  ex- 
aminer. 

The  chief  signs  of  a  normal  prostate  are: 

The  lobes  are  flaccid,  flat,  insensitive. 

An  exquisitely  sensitive  prostate  (like  an  exquisitely  sensitive 
urethra)  may  be  anatomically  normal.  A  sensitive  and  tense  prostate 
usually  contains  pus.  A  prostate  with  rounded,  tense  insensitive  lobes 
is  usually  hypertrophied,  but  may  be  simply  inflamed.  The  relative 
roundness  of  the  lobes  is  appreciated  by  sweeping  the  finger  across  them 
from  side  to  side. 

A  prostate  may  be  inflamed  or  enlarged  or  the  seat  of  neoplasm 
and  yet  feel  normal  to  rectal  touch. 

Cystoscopy  and  rectal  palpation  upon  a  sound  in  the  urethra  (p.  315) 
are  of  great  assistance  in  diagnosis  of  carcinoma  of  the  prostate. 

There  are  no  indurations  in  or  about  the  prostate. 

Discrete  round  masses  on  or  near  the  prostate  are  usually  glands  or 
phleboliths.  Indurations  within  the  lateral  lobes  or  projecting  toward 
the  seminal  vesicles  are  usually  inflammatory ;  they  may  be  tuberculous 
or  neoplastic.  Indurations  extending  from  the  prostate  into  the  base 
of  the  bladder  beyond  are  invariably  neoplastic. 

Examination  of  the  Vesicles. — The  distinction  between  the  seminal 
vesicle  and  the  ampulla  of  the  vas  is  not  possible  by  rectal  touch.     If 


EXTERNAL  EXAMINATION  OP  GENITO- URINARY  TRACT        d 

the  perineum  is  deep  or  the  prostate  enlarged  it  may  be  impossible  to 
insert  the  finger  far  enough  up  the  rectum  to  reach  the  vesicle. 

The  normal  seminal  vesicle  is  impalpable. 

The  dilated  or  inflamed  seminal  vesicle  is  felt  as  an  irregular, 
elongated  mass  beginning  just  above  the  prostate,  laterally,  and  ex- 
tending upward  or  upward  and  outward  beyond  the  reach  of  the  finger. 
If  greatly  enlarged  the  vesicles  may  meet  in  the  middle  line,  but  usu- 
ally there  is  a  space  about  a  finger's  breadth  in  width  between  them. 
The  inflamed  vesicle  feels  doughy  or  doughy  and  lumpy. 

Examination  of  the  vesicles  may  sojnetimes  be  made  easier  by  coun- 
terpressure  on  the  hypogastrium. 

A  vesicle  may  be  inflamed  and  yet  feel  normal  to  rectal  touch. 

Examination  of  the  Base  of  the  Bladder — Neoplasms  of  the  bladder 
and  large  stones  in  the  lower  end  of  the  ureter  may  sometimes  be  felt 
by  rectal  touch  in  the  space  between  the  vesicles.  Counterpressure  on 
the  abdomen  is  of  assistance  in  this  examination. 

Abdominorectal  palpation  sometimes  reveals  stones  in  the  bladder, 
but  in  this  respect  the  examination  is  likely  to  be  extremely  misleading. 

PALPATION  OF  THE  PENIS  AND  UEETHEA 

Palpation  of  the  Penis — This  presents  no  peculiar  difficulty  other 
than  that  of  identifying  obscure  circumscribed  fibroses  in  the  corpora 
cavernosa. 

Palpation  of  the  Urethra — The  urethra  should  be  palpated  upon  a 
sound  just  large  enough  to  fill  it  without  distention.  Careful  palpa- 
tion upon  this  reveals  even  the  smallest  infiltrations  in  and  about  the 
urethral  wall. 

Only  the  anterior  urethra  can  be  palpated  externally.  The  mem- 
branous urethra  must  be  palpated  from  the  rectum.  The  prostatic 
urethra  can  scarcely  be  palpated. 

PALPATION  OF  THE  SCROTAL  CONTENTS 

Palpation  of  the  Testicle — The  testicle  should  be  palpated  by 
slipping  it  to  and  fro  between  the  thumb  and  the  index  finger.  The 
chief  characteristics  to  be  noted  are  its  size  and  tension  as  compared 
with  its  fellow,  the  condition  of  the  epididymis,  the  presence  of  hydro- 
cele, and  of  pathologic  conditions  in  and  about  the  testicle. 

The  normal  epididymis  must  be  carefully  palpated  many  times  be- 
fore the  examiner's  fingers  attain  complete  familiarity  with  its  usual 
variations  in  size,  consistence,  and  attachment  to  the  testicle. 

The  presence  of  hydrocele  is  often  a  confusing  element  indiag-nosis. 
Here  again  familiarity  with  the  tension  of  a  normal  testicle  and  with 


10  PHYSICAL  EXAMINATION 

the  groove  that  separates  it  from  the  epididymis  makes  the  alteration 
of  that  tension  and  the  obliteration  of  that  groove  by  hydrocele  imme- 
diately recognizable. 

Palpation  of  the  Vas  Deferens — The  physician  should  also  accus- 
tom his  fingers  to  follow  the  vas  from  its  origin  at  the  tail  of  the 
epididymis  up  to  and  into  the  inguinal  canal,  in  order  to  recognize 
changes  in  its  size  or  sensitiveness. 


INTERNAL  EXAMINATION 

The  technic  of  passing  urethral  instruments  and  of  using  the 
urethroscope,  the  cystoscope,  and  the  ureter  catheter  is  taken  up  in  the 
following   chapters. 


CHAPTER    II 
URINALYSIS 

The  foundation  of  urology  is  urinalysis.  Without  a  thorougli  prac- 
tical familiarity  with  this  art  as  practiced  in  the  laboratory  and  in  the 
clinic,  no  man  may  expect  to  diagnose  diseases  of  the  urinary  organs. 

The  practice  of  lu'inalysis  is  twofold:  laboratory  urinalysis  and 
clinical  urinalysis. 

LABORATORY  URINALYSIS 

In  the  laboratory  the  urine  is  subjected  to  tests  for  acidity,  specific 
gravity,  albumin,  sugar,  indican,  etc. ;  it  is  centrifuged  and  the  cel- 
lular, crystalline,  and  bacterial  content  of.  the  sediment  noted. 

Such  an  analysis  every  physician  must  be  competent  to  perform. 
There  is  no  special  need,  therefore,  to  dwell  upon  it  here,  except  to  insist 
upon  certain  points  of  peculiar  interest  to  the  urologist. 

THE   SELECTION   OF   THE   SPECIMEN 

This  is  of  the  greatest  importance.  Unless  the  patient's  general 
health  and  the  examination  of  a  single  specimen  warrant  the  belief  that 
the  kidneys  are  sound  a  twenty-four-hour  specimen  should,  of  course, 
be  examined'. 

But  this  is  not  enough.  The  urologist  is  chiefly  interested  in  the 
bacterial  and  cellular  content  of  the  urine.  This  he  wishes  to  examine 
without  contamination  (if  possible)  by  the  secretions  of  the  urethra  or 
of  the  vagina.  Hence i^e  specimen  for  microscopical  examination  must 
be  obtained  direct  from  the  Madder.  To  accomplish  this  it  is  best  to 
draw  the  urine  by  catheter;  though  sometimes  it  is  sufficient  to  have 
the  patient  urinate  into  two  glasses  (as  described  below)  and  to  ex- 
amine the  contents  of  the  second  glass.  This  precaution  is  even  more 
useful  for  the  analysis  of  the  urine  of  women  than  of  men,  though 
this  is  not  generally  recognized.^  The  two-glass  test  is  misleading  in 
women,  as  the  first  urine  passed  docs  not  necessarily  clean  out  all  the 
vaginal  pus. 

^Such  special  methods  of  obtaining  urine  as  suprapubic  puncture,  ureteral  cathe- 
terization, etc.,  do  not  enter  into  the  present  discussion. 

ii 


12  URINALYSIS 

The  old-fasliioued  metliod  of  examining  tlie  "morning"  and  "night" 
specimens  of  urine  has  been  generally  discarded  in  favor  of  the 
"twenty-four-hour"  specimen.  Yet  in  estimating  the  cause  of  nocturnal 
frequency  of  urination,  especially  in  persons  past  middle  age,  a  com- 
parative quantitative  examination  of  the  urine  passed  between  9  p.m. 
and  9  a.m.  and  that  passed  between  9  a.m.  and  9  p.m.  is  often  impera- 
tive. Without  it  one  cannot  decide  whether  nocturnal  frequency  of 
urination  is  due  to  the  polyuria  of  arterial  disease  or  to  prostatism  or 
some  other  local  irritant. 

Thus  a  complete  laboratory  urinalysis  consists  of — 

1.  Chemical  and  physical  examination,  qualitative  and  quantita- 
tive, of  a  "twenty-four-hour"  specimen. 

2.  Microscopical  (and  bacteriological)  examination  of  the  centri- 
fuged  sediment  of  the  bladder  urine,  obtained  by  catheter  or  by  the  two- 
glass  method. 

3.  In  certain  cases  a  comparative  examination  of  "night"  and 
"day"  urines. 

THE    ANALYSIS 

The  tests  that  suffice  for  most  cases  are: 
Physical  Tests — 
Reaction. 
Specific  Gravity. 
Chemical  Tests — 
Urea. 

Albumin  (quantitative). 

Sugar  (quantitative)   (acetone,  etc.,  if  sugar  is  found). 
Indican. 
Phosphates. 
Microscopical  Examination — 
Crystals   (  differential ) . 
Blood  and  pus  cells. 
Epithelial   cells    (differential). 
Casts  (differential). 

Bacteria  (differential),  especially  the  gonococcus  and  the  bacil- 
lus of  tuberculosis. 
Albumin. — Upon  the  meaning  and  importance  of  the  physical  and 
chemical  tests  we  need  not  dwell,  except  to  insist  that  the  statement  so 
commonly  made  that  "albumin  is  accounted  for  by  pus"  is  almost  in- 
variably inaccurate,  and  often  fatally  misleading.  The  urine,  mixed 
with  about  one-fifth  of  its  bulk  of  normal  salt  solution  and  then  tested 
for   albumin,^    never   shows   more   than   a   trace    except   under   three 

^  For  qualitative  analysis  the  acetic-and-heat  and  the  nitric-ring  tests  are  the  best. 
The  former  is  the  more  delicate  if  properly  performed,  thus: 


LABORATORY  URINALYSIS  13 

conditions:    (1)   Kephritis.      (2)   Acute  prostatitis.      (3)   Hematuria. 

So  long  as  there  is  much  blood  in  the  urine,  or  acute  prostatitis,  a 
moderate  albuminuria  has  no  great  significance,  but  in  the  absence  of 
these,  and  even  in  the  presence  of  slight  microscopic  hemorrhage  or  of 
chronic  prostatitis,  the  appearance  in  the  urine  of  one-tenth  of  one  per 
cent  of  albumin  (by  weight)  means  nephritis,  and  if  there  is  pyuria, 
pyelonephritis.     No  amount  of  pus  will  liberate  so  much  albumin. 

The  importance  of  this  fact  is  great,  for  the  gravest  cases  of  pyelo- 
nephritis may  evoke  no  symptoms  directly  referable  to  the  kidney,  and 
may  deliver  urine  in  which  the  few  kidney  casts  are  overwhelmed  in 
pus  and  may  be  overlooked  by  even  the  most  paiitstaking  search.  In  this 
event  the  amount  of  albumin  in  the  urine  is  the  first  hint  that  the  kidney 
is  involved. 

Epithelial  Cells. — The  debate  as  to  the  ability  of  the  microscopist  to 
identify  epithelial  cells  from  the  ureter  and  the  renal  pelvis  has  been 
on  for  a  generation  and  is  still  open.  The  frequent  opportunity  of  ex- 
amining specimens  of  urine  obtained  by  the  ureteral  catheter  has  of  late 
years  educated  many  men  to  the  point  of  making  this  diagnosis  with 
reasonable  certainty.  A  quantity  of  round  and  polyhedral  cells  little 
larger  than  a  pus  cell  can  only  come  from  the  kidney,  pelvis,  or  ureter. 
A  few  round,  small  cells  may  be  desquamated  in  prostatitis,  but  these 
are  accompanied  by  very  large  round  prostatic  cells,  and  usually  by 
squamous  bladder  cells.  Moreover,  these  prostatic  cells  may  often  be 
eliminated  by  using  the  two-glass  test  or  by  drawing  the  urine  by 
catheter. 

Accuracy  in  this  diagnosis  cannot  be  learned  from  a  text-book,  but 
must  be  obtained  from  a  study  of  specimens  obtained  by  the  ureteral 
catheter. 

Bacteria. — Smear,  culture  and  inoculation  are  all  employed  in  the 
differentiation  of  urinary  bacteria.  Perhaps  the  most  useful  device 
for  immediate  diagnosis  is  Crabtree's  fractional  centrifuging  ^  with  the 
high-speed  electric  centrifuge. 

1.  The  filtered  urine  (four  parts)  and  salt  solution  (one  part)  mixture  in  a 
test-tube  is  held  over  a  Bunsen  flame  so  as  to  boil  only  its  upper  2  cm. 

2.  To  this  is  added,  without  shaking,  one  or  two  drops  of  acetic  acid. 

3.  If  a  cloud  of  phosphates  is  thrown  down  by  the  boiling  and  partially  re- 
dissolved  by  the  acid,  the  test-tube  is  shaken  just  enough  to  dissolve  the  rest  of  this. 

4.  The  mixture  is  once  more  boiled. 

5.  The  upper  portion  of  the  fluid  is  examined  by  means  of  a  cainera  obscura. 
This  step  is  the  most  important  of  all.  The  camera  consists  of  a  small  box,  black 
inside,  with  a  vertical  slit  on  one  side  to  admit  the  light,  a  round  hole  in  tiie  bottom 
to  admit  the  test-tub^,  and  a  flap  fixed  like  an  open  cover  to  conceal  the  source  of 
light  (an  incandescent  bulb  is  better  than  daylight).  The  light  striking  the  fluid 
suffuses  it  and  plainly  sKows  against  the  darkness  inside  the  camera  an  albuminous 
cloud  that  would  otherwise  elude  observation. 

^  Surg.,  Gynec.  and  Obstet.,  1916,  xxii,  221. 


14  URINALYSIS 

If  the  urine  contains  considerable  pus,  centrifuge  for  one  to  two  minutes 
at  the  lowest  speed.  The  bulk  of  the  pus  and  detritus  will  be  thrown  down  in 
a  heavy  sediment  leaving  a  somewhat  cloudy  urine  above  containing  a  few  pus- 
cells  and  the  majority  of  the  bacilli.  Decant  the  urine  into  a  clean  tube,  discard 
the  sediment,  and  eentrifugalize  the  urine  at  high  speed  until  it  is  clear.  This 
step  requires  15  to  30  minutes.  The  urine  may  be  then  decanted  and  the  tube 
containing  the  sediment  refilled  with  partly  clarified  urine  and  replaced  in  the 
centrifuge.  In  this  way  the  contents  of  two  or  more  tubes  of  urine  may  be 
concentrated  into  a  single  small  sediment.  Pour  off  the  urine,  invert  the 
centrifuge  tube  on  a  towel  and  drain  off  the  last  drops.  A  fairly  dry  small 
sediment  will  be  obtained  which  can  be  removed  with  a  loop,  and  cover-glass 
preparations  made,  or  cultures  planted. 

In  those  urines  which  contain  but  little  pus,  experience  has  shown  that  pre- 
liminary eentrifugalization  is  unnecessary.  The  important  step  in  the  pro- 
cedure is  to  eentrifugalize  the  urine  until  clear  to  ensure  deposit  of  the  bacilli. 

Special  precautions  are  required  for — 

1.  Diagnosis  of  the  gonococcus  (p.  108),  and 

2.  Diagnosis  of  the  bacillus  of  tuberculosis  (p.  424). 


CLINICAL  URINALYSIS 

On  the  score  of  common  knowledge  we  have  skimped  the  description 
of  laboratory  analysis  to  make  room  for  detailed  description  of  the 
special  knowledge  required  for  a  competent  clinical  urinalysis,  without 
which  the  urologist  is  hopelessly  at  sea. 

Clinical  urinalysis  consists  in  loohing  at  the  urine  and  interpreting 
what  we  see  therein.  It  suggests  the  nature  and  quantity  of  substances 
held  in  suspension  in  the  urine.  It  suggests,  also,  in  many  instances,  the 
part  of  the  urinary  tract  from  which  these  substances  are  derived. 
But  it  is  by  no  means  infallible,  a7id  its  findings  must  always  he  con- 
firmed hy  laboratory  urinalysis  and  by  a  physical  examination  of  the 
patient. 

These  propositions  are  fundamental.  They  seem  to  leave  a  very 
small  place  in  the  diagnosis  for  this  clinical  test  whose  only  function  is 
to  suggest  and  not  to  prove.  Yet,  practically  speaking,  clinical  urinal- 
ysis is  employed  far  more  constantly  than  the  laboratory  tests.  At  the 
first  examination  of  a  case  it  often — very  often — gives  the  suggestion 
that  leads  ultimately  to  correct  diagnosis,  and  in  subsequent  examina- 
tions it  is  our  chief  means  of  judging  the  progress  of  the  case. 

At  the  patient's  first  visit,  therefore,  the  urine  should  be  carefully 
inspected  before  it  is  submitted  to  laboratory  tests,  though  the  infer- 
ences made  from  inspection  should  not  be  acted  upon  unless  the  labora- 
tory confirms  them.  At  subsequent  visits,  on  the  other  hand,  clinical 
examination  of  the  urine  by  inspection  is  always  imperative,  while  labo- 
ratory examination  is  only  required  from  time  to  time. 


CLINICAL  URINALYSIS  15 

TECHNIO  OF  CLINICAL  URINALYSIS 

It  is  by  no  means  a  waste  of  time  to  describe  precisely  what  is 
meant  by  "looking  at  the  urine."  This  does  not  mean  looking  at  it  as 
it  lies  in  the  bottom  of  an  opaque  vessel ;  it  does  not  mean  looking  at  it 
after  it  has  shaken  about  in  a  bottle  in  the  patient's  pocket  for  hours; 
it  does  not  even  mean  glancing  at  it  casually  in  a  dirty  glass  and  by  an 
imperfect  light.    What  it  does  mean  is  this : 

Let  the  patient  present  himself  for  examination  at  least  two,  and  if 
possible  three  or  four,  hours  after  his  last  urination.  Let  him  pass  into 
a  large,  clean  tumbler  (a  pint  glass  is  the  best  size)  about  50  c.c.  of  his 
urine,  the  rest  into  a  second  glass. 

Now  examine  the  contents  of  these  two  glasses  against  a  strong 
light.  ISTo  speck  or  cloud  in  them  is  too  insignificant  to  be  noticed. 
View  them  intently  and  begin  to  draw  tentative  conclusions,  recognizing 
that  these  conclusions  are  not  final,  but  only  important  hints.  "This 
is  a  foreign  body."  "This  is  a  shred  which,  to  judge  by  its  size,  comes 
from  the  anterior  urethra.  There  is  a  speck  of  blood  adherent  to  it." 
"This  haze  is  opalescent,  and,  therefore,  probably  crystalline  or  bac- 
terial." "This  swirl  of  fresh  blood  still  undistributed  is  more  probably 
vesical  or  prostatic." 

Such  are  a  few  of  the  thousand  and  one  inferences  drawn  by  the 
expert  examiner.  By  making  such  inferences  and  confirming  or  refut- 
ing them  in  the  laboratory  or  by  physical  examination,  one  soon  learns 
to  make  rapid  and  accurate  inferences  from  data  imperceptible  to  the 
inexperienced  eye. 

The  accuracy  of  these  inferences  may  be  increased  by: 

1.  The  acetic  acid  test. 

2.  The  comparison  of  the  contents  of  the  first  and  second  glass  (for 
men  only). 

3.  Comparison  with  these  of  a  third  glass  of  urine  (for  those  cases 
in  which  the  two-glass  test  might  prove  misleading) . 

The  Acetic  Acid  Test. — The  substances  held  in  suspension  in  the 
urine  are  organic  and  crystalline.  The  former  (pus,  blood,  bacteria, 
etc.)  form  the  object  of  the  clinical  examination,  while  the  latter  (crys- 
tals), though  of  considerable  importance  in  the  general  diagnosis,  are 
only  confusing  here.  Their  presence  simply  obscures  the  undissolved 
organic  content  of  the  urine. 

ISTow  of  the  various  crystals  that  may  cloud  the  urine,  the  earthy 
phosphates  are  the  commonest  and  the  most  important.  Urates  and 
uric  acid  are  rarely  seen  in  any  quantity  in  freshly  passed  urine  (and 
their  reddish  color  distinguishes  them),  oxalates  or  cystin  scarcely  ever 


16  URINALYSIS 

occur  in  sucli  qiiantitv  as  to  cloud  the  urine/  but  the  phosphates  are 
common  and  readily  soluble  by  acidulation  of  the  urine. 

Therefore,  if  examination  of  the  urine  in  two  glasses  shows  that  both 
are  cloudy  (for  the  phosphatic  cloud  appears  in  both  urines  -)  the 
glass  containing  the  second  urine  is  held  against  the  light  and  a  few 
drops  of  acetic  acid  poured  down  its  side.  If  phosphates  are  present, 
there  follows  instant  effer^^escence  (from  the  breaking  up  of  carbon- 
ates that  are  always  associated  with  phosphates)  and  clearing  of  the 
urine. 

This  clearing  may  be  interfered  with  in  only  two  ways,  viz. :  by 
the  presence  in  the  urine  of  insoluble  substances  (crystalline  or  organ- 
ized), the  nature  of  which  must  be  determined  by  microscopic  analysis, 
and  by  the  presence  of  copaiba  in  the  urine.  The  urine  of  a  phosphaturic 
patient  taking  copaiba  clears  only  for  an  instant,  and  then  becomes 
cloudy  again,  the  copaibal  cloud  being  only  a  little  less  opalescent  than 
the  phosphatic  cloud  which  it  replaces. 

When,  therefore,  we  know  from  previous  microscopic  analysis  the 
nature  of  the  insoluble  substances  in  a  patient's  urine,  and  know,  also, 
that  he  is  not  taking  copaiba,  the  acetic  acid  test  is  used  as  the  simplest 

^  I  have  several  times  seen  an  oxalate  cloud,  once  a  eystin  cloud.  They  produce 
the  same  opalescent  haze  as  do  phosphates  or  bacteria,  and  are  distin^ishable  only 
by  the  microscope. 

^When  the  phosphates  are  in  great  excess  they  are  not  distributed  evenly 
throughout  the  urine  but,  having  settled  in  the  bladder,  are  most  concentrated  in 
the  last  drops.  In  extreme  phosphaturia  this  concentration  of  crystals  in  the  last 
drops  is  so  marked  that  the  patient  can  occasionally  squeeze  from  the  urethra  little 
gritty  masses  of  phosphates  left  there  after  urination  is  complete. 

The  characteristics  of  this  pliospliaiuria,  as  it  is  called,  are  the  follo-sving:  It 
occurs  almost  exclusively  in  youth,  between  the  age  of  fifteen  and  thirty-five.  It  is 
apparently  due  to  a  functional  disturbance  in  assimilation,  and  is  therefore  commonly 
seen  in  young  persons  who  work  with  their  heads  rather  than  with  their  hands,  is 
often  associated  with  functional  dyspepsia,  and  like  this  is  most  marked  at  periods 
of  mental  stress.  It  never  causes  stone  or  inflammation  of  the  urinary  passages,  and 
its  association  with  pus  in  the  urine  is  purely  accidental.  Its  chief  clinical  char- 
acteristic is  its  sudden  appearance  and  disappearance;  at  one  micturition  the  urine 
is  milky  with  phosphates,  at  the  next  absolutely  sparkling  and  clear.  Its  prognosis 
is  good;  it  gradually  lessens  with  age;  it  does  no  harm.  The  sexual  neurasthenic  of 
course  looks  upon  it  with  horror,  and  for  the  mental  relief  of  such  persons  treatment 
of  the  phosphaturia  is  required. 

First,  one  should  insist  that  the  phosphaturia  is  harmless  in  itself  and  only  a 
sign  of  functional  derangement.  Secondly,  one  must  insist  upon  a  strict  regime  of 
diet  and  exercise  appropriate  to  the  existing  nervous  or  digestive  disturbance.  Thirdly, 
one  must  remember  that  a  direct  attack  upon  the  phosphaturia  by  drugs  is  usually 
a  failure,  and  if  successful  is  only  of  temporary  efficacy.  Hexamethylenamin,  salol, 
benzoate  of  soda,  and  other  urinary  acidifiers  have  a  reputation  beyond  their  merits. 
Ten  drops  of  dilute  hydrochloric  acid  before  each  meal  I  have  found  more  efficacious 
than  anything  else,  but  our  main  reliance  is  hygiene,  especially  as  to  diet  and 
exercise. 


CLINICAL  URINALYSIS  17 

method  of  removing  a  chance  phosphatic  clond,  as  a  routine  preliminary 
to  the  clinical  examination  of  the  nrine. 

Comparison  of  the  First  and  Second  Urines — Having  tested  for 
phosphates  bv  the  addition  of  a  few  drops  of  acetic  acid,  and  dissolved 
these,  if  present,  by  adding  an  excess  of  this  acid,  the  physician  holds 
the  two  glasses  into  which  the  patient  has  passed  his  urine  against  the 
light  and  compares  their  contents.^ 

The  first  urine  passed  is  the  urine  as  it  lay  in  the  bladder,  plus  what 
it  has  swept  from  the  urethral  walls. 

The  second  urine  passed  is  the  urine  as  it  lay  in  the  bladder,  without 
admixture  of  anything  gathered  from  the  urethra  during  its  exit.^ 

This  rule  has  but  two  exceptions,  as  follows:  (1)  If  the  insoluble 
substances  suspended  in  the  bladder  urine  are  very  dense  they  may 
settle  to  the  bottom  as  the  urine  lies  in  the  bladder  and  come  away 
chiefly  with  the  last  drops  of  urine.  The  substances  which  fall  within 
this  exception  are  blood-clots,  crystals  (usually  phosphates),  and  pus, 
when  present  in  great  quantity  (such  as  usually  comes  from  pyone- 
phrosis). 

(2)  The  second  urine  may  also  be  contaminated  by  whatever  may  be 
squeezed  from  the  urethral  wall  during  the  ^'piston  stroke"  muscular 
spasm  that  clears  the  urethra  of  the  last  drops  of  urine.  Under  this  ex- 
ception come  pus  squeezed  from  the  prostatic  ducts  (or  from  a  prostatic 
abscess)  when  the  prostate  is  gravely  inflamed,  and  blood  squeezed  from 
the  bladder  neck  (or  from  the  adjoining  surface  of  the  bladder  or 
urethra)  when  this  is  acutely  inflamed,  ulcerated,  or  the  seat  of  neo- 
plasm. 

These  exceptions  amount  clinically  to  this: 

*  Comparative  examination  of  the  two  urines  is  of  no  interest  if  the  patient  is  a 
woman  since  the  differences  in  them  are  chiefly  accounted  for  by  the  vaginal  secretion 
in  the  first  glass.  It  is  scarcely  necessary  to  add  that  examination  of  a  third  glass 
is  equally  inapplicable  to  women. 

2  This  elementary  physical  fact  that  the  first  fluid  flushes  the  outlet  and  the 
second  comes  clean  from  the  tank  would  scarcely  require  explanation  were  it  not  for 
the  fact  that  so  many  physicians  believe  that  the  first  urine  passed  shows  the  contents 
of  the  anterior  urethra,  the  second  those  of  the  posterior  urethra.  This  fundamental 
error  is  fostered  by  the  clinical  fact  that  the  contents  of  the  posterior  urethra  are 
often  mingled  with  those  of  the  bladder  before  urination.  In  this  event  the  first 
urine  passed  contains  what  it  sweeps  from  anterior  and  posterior  urethra  during  the 
urination,  plus  what  has  entered  the  bladder  from  the  posterior  urethra  between 
urinations,  while  the  second  urine  contains  only  what  has  flowed  back  into  the  bladder 
from  the  posterior  urethra,  between  urinations  (supposing  the  bladder  and  kidneys 
add  no  contamination).  Thus  the  comparison  of  tin?  two  urines  may  under  certain 
conditions  show  one  the  content  of  the  anterior  urethra,  plus  that  of  the  posterior 
urethra,  the  second  only  that  of  the  posterior  urethra,  and  under  these  special  condi- 
tions the  first  urine  does  roughly  represent  the  anterior  urethral  washings,  the  second 
urethra  the  posterior.  But  to  step  from  this  particular  to  a  broail  generalization  is 
inaccurate  and  misleading  both  in  theory  and  in  practice. 


18  UEINALYSIS 

The  two-glass  test  7nay  mislead  in  the  presence  of  bleeding  or  of 
active  suppuration  in  prostate  or  kidney. 

The  Three-glass  Test. — For  such  cases  a  still  further  hint  (none  of 
these  tests  is  proof)  as  to  the  conditions  present  may  be  obtained  by 
making  the  patient  pass  his  urine  in  three  glasses  instead  of  two  without 
interrupting  the  flow  of  urine  in  transferring  from  one  glass  to  another. 
The  three  specimens  thus  obtained  represent: 

1.  Bladder  urine  (less  sediment),  plus  washings  of  urethra. 

2.  Bladder  urine  (less  sediment). 

3.  Bladder  urine,  plus  sediment  or  substances  expressed  by  "pis- 
ton stroke." 

Yet  this  test  is  very  rarely  employed,  since  its  disclosures  are  con- 
fusing (failure  to  determine  the  derivation  of  the  contents  of  the  third 
glass),  and  require  verification  by  other  methods  of  examining  prostate, 
bladder,  and  kidneys,  which  methods  are  themselves  far  more  accurate 
than  this  three-glass  test. 

Another  three-glass  test  frequently  employed  as  an  aid  in  the  diag- 
nosis of  chronic  prostatitis  or  vesiculitis  is'  the  following :  The  patient 
urinates  into  two  glasses,  but  retains  some  urine  in  the  bladder.  The 
physician  then  massages  the  prostate  or  the  vesicles  (or  both),  and  the 
patient  then  passes  into  a  third  glass  the  remaining  urine,  carrying  with 
it  the  expressed  secretion  from  the  glands  massaged. 

This  test  is  accurate  only  in  case  the  second  urine  is  quite  clear,  and 
is  necessary  only  when  it  is  impossible  to  squeeze  from  the  suspected 
gland  enough  secretion  to  make  it  appear  at  the  meatus,  and  when  the 
instrumentation  necessary  to  fill  the  bladder  with  a  clean  solution 
before  massage  is  impracticable. 

Other  Tests. — A  variety  of  tests  involving  the  use  of  a  greater 
number  of  glasses  have  been  devised  for  the  specific  purpose  of  locating 
inflammation  in  the  anterior  or  posterior  urethra  exclusively.  Their 
complexity  is  such  that  they  are  of  no  practical  value. 

THE   ESSENCE   OF   CLINICAL  URINALYSIS 

The  results  to  be  expected  from  any  of  these  methods  of  clinical 
Urinalysis  are  directly  proportionate  to  the  skill  of  the  examiner.  The 
essence  of  the  test  is  his  ability  to  distinguish  at  a  glance  slight  varia- 
tions in  the  amount  and  quality  of  pus,  blood,  or  shreds  present.  Thus 
clinical  urinalysis  is  of  the  greatest  use  for  the  prognosis  from  day 
to  day.    As  a  diagnostic  test  of  the  nature  of  disease  it  is  at  its  weakest. 


CHAPTEK   III 
URETHRAL  INSTRUMENTS:  THEIR  ASEPSIS 

URETHRAL  INSTRUMENTS 

The  axiom  that  a  good  workman  does  not  complain  of  his  tools 
implies  in  him  appreciation  and  possession  of  adequate  instruments. 
The  urologist,  therefore,  must  thoroughly  understand  the  nature,  the 
care,  and  the  use  of  urethral  instruments. 

In  the  selection  of  urethral  instruments  no  two  authorities  can  be 
expected  to  agree.  Thus  the  specialist  can  afford  to  employ  many  in- 
struments which  would  be  useless  in  less  expert  hands.  But  certain 
instruments  are  required  by  every  man  wishing  to  do  good  urological 
work.  All  of  these  we  believe  to  be  included  in  the  following  list. 
Thfi  latter  may  be  enlarged  according  to  the  fancy  of  the  physician; 
on  the  other  hand,  it  may  .be  diminished  by  omitting  the  instruments 
bracketed. 

A  set  of  conical  sounds.     (ISTo.  15  to  32  French.) 

A  set  of  olivary-tipped  conical  woven  bougies.      (No.   10  to   20 
French. ) 

[A  set  of  bulbous  bougies.] 

Kollmann  dilators. 

Filiform  bougies. 

[A  set  of  tunneled  sounds,  catheters  and  filiforms.] 

[A  set  of  Janet  steel  sounds  and  filiforms.] 

Soft-rubber  catheters.     (No.  15  to  20  French.) 

Woven  olivary  "natural  curve"  catheters. 

[Indwelling  catheters.] 

An  elbowed  obturator. 

Urethroscopes  and  attachments. 

Cystoscopes,  ureteral  catheters,  etc. 

[Silver  catheters.] 

[Stone  searcher.] 

A  200  c.c.  syringe. 

Urethral  injection  syringes. 

An  instillator.     (Keyes,  Bangs  or  Guyon  type.) 

Nozzles  and  apparatus  for  anterior  urethral  irrigation.' 

19 


20  URETHRAL  INSTRUMENTS:  THEIR  ASEPSIS 

SCAIiES 

The  scale  for  grading  the  caliber  of  urethral  instruments  was  first 
accurately  fixed  in  France,  where  two  scales  are  at  present  in  use — ^the 
Charriere  (commonly  known  as  the  French  scale)  and  the  Benique. 
Other  scales  are  the  English  and  the  American. 

Of  late  years  the  tendency  in  this  country,  as  well  as  in  England, 
has  been  to  adopt  the  French  scale  as  the  most  convenient,  while  in 
France  itself  there  is  a  tendency  to  replace  the  old  French  (Charriere) 
by  the  new  Benique  scale.  Although  Dr.  Van  Buren,  senior  author  of 
the  parent  edition  of  this  work,  was  very  tenacious  of  the  American 
scale — which,  indeed,  was  born  in  his  office — ^the  almost  universal  adop- 
tion of  the  French  scale  since  his  time  has  led  us  to  drop  the  American 
in  favor  of  the  French  scale. 

The  French  (Charriere)  scale  indicates  diameters  in  ^  mm.  Xo.  1 
has  a  diameter  of  ^  mm.,  jSTo.  2  a  diameter  of  f  mm.,  and  so  on. 
From  this  scale,  therefore,  the  diameter  of  an  instrument  may  be  deter- 
mined by  dividing  its  number  by  3.  A  ISTo.  30  sound  has  a  diameter  of 
30  mm.  -^-  3  =  10  mm. 

The  Benique  scale  indicates  diameters  in  ^  mm.  It  numbers  instru- 
ments twice  as  high,  therefore,  as  the  Charriere.  A  'No.  30  French 
sound  is  a  'No.  60  Benique.    B.  =  F.  X  2. 

The  American  scale  indicates  diameters  in  ^  mm.  30.  F.  :^  60  B 
=  20  A.    A.  =  f  F. 

The  English  scale  follows  no  rule,  but  its  numbers  are  generally 
about  2  less  than  the  American.  Thus,  30  F.  =  60  B.  =  20  A.  = 
18  E.    E.  =::(A.  orfF.)  —2. 

SOUNDS  AND  BOUGIES 

A  metal  instrument  for  urethral  exploration  is  commonly  tenned  a 
sound  (though  a  bulbous  bougie  may  be  metallic),  while  a  flexible 
instrument  (made  of  woven  silk  and  varnished)  is  called  a  bougie. 

The  best  woven  instruments  are  made  in  France.  In  order  to 
spare  the  patient's  meatus,  I  have  all  my  sounds  above  24  F.  size  made 
with  double  taper  (Fig.  1). 

American  custom  favors  the  use  of  the  single-curve  sound  (Fig. 
1),  while  European  custom  favors  the  double-curve  or  Benique  instni- 
nient  (Fig.  6).  After  many  years'  use  of  the  former,  I  have  discarded 
them  in  favor  of  the  latter. 

Conical  Woven  Bougies  (Fig.  2). — These  should  be  olivary  tipped. 
Inasmuch  as  they  are  used  to  dilate  strictures  up  to  the  point  where 
steel  sounds  may  be  used,  one  should  possess  a  complete  set  from  10  to 
20  French  size.     The  neck  of  the  instrument  should  be  quite  flexible. 


UEETHRAL  INSTRUMENTS 


21 


Bulbous  Bougies  (Eig.  3). — Bulbous  bougies  may  be  flexible  or 
metallic.  The  best  French  makes  of  flexible  bougies  are  almost  as 
durable  as  and  more  useful  than  the  metallic  instruments. 


N     ^^ 


..J 


Fig.  2. — Olivary 
Bougie. 


„,   21!  , 

I    'II  mi 


Fig.  1 — Double   Taper 

Sound. 


Fig.  3. — Bulbous 
Bougie. 


Fig.  4. — Kollmann  Dilatohs. 


Kollmann  Dilators  (Fig.  4). — These  are  useful  for  dilating  the 
urethra  while  sparing  the  patient  the  insig-nificant  operation  of  meat- 
otomy,  and  also  to  carry  dilatation  to  great  lengths.  The  Oberlaender, 
Frank,  and  Thompson  dilators  are  inferior  to  the  Kollmann. 


22 


TJRETHEAL  IN'STEUMENTS :  THEIR  ASEPSIS 


The  best  models  of  these  dilators  are  made  of  pure  nickel  by 
Gentile  in  Paris.  The  nickel  does  not  rust,  and  the  instrument  may 
therefore  be  sterilized  by  boiling. 

This  dilator  is  made  in  several  designs,  some  of  which  have  irri- 
gating attachments.  The  two  types  illustrated 
are  the  ones  generally  employed. 

Filiform  Bougies   (Fig.  5). — Filifonn  bou- 
gies are  made  of  whalebone  or  of  woven  silk. 


Fig.  5. — Whalebone  Fil- 
iform AND  Tunneled 
Sound 


Fig.    6. — Woven    Filiform   and 

Janet  Sound. 


Their  average  size  is  3  French ;  they  should  be  olive  tipped.  The  choice 
between  whalebone  and  woven  filiforms  is  largely  a  matter  of  taste. 
Both  are  fragile,  liable  to  break  off  in  the  urethra,  and  therefore  old, 
frayed,  and  ragged  filiforms  should  he  instanthj  discarded. 

Inasmuch  as  filifonns  are  used  chiefly  as  pathfinders  for  larger 


URETHRAL  INSTRUMENTS 


23 


instruments,  the  choice  of  filiforms  depends  largely  upon  the  instru- 
ments which  are  to  follow.  Two  combinations  are  possible,  viz. :  the 
whalebone  filiform  and  the  tunneled  sound  (Fig.  5),  the  French  woven 
filiform  and  the  Janet  sound  (Fig.  6). 

The  excellence  of  our  whalebone  instruments  and  the  difficulty  of 
obtaining  satisfactory  woven  filiforms,  have  made  the  whalebone-tun- 
neled-sound  combination  the  popular  one  in  this  country,  in  spite  of  its 
mechanical  inferiority.-^ 

The  combination  of  a  good  woven  filiform  and  a  Janet  sound  (a 
set  of  these  should  contain  at  least  every  alternate  number  from  10  to 
20  French)  is  better,  both  because  of  its  smoothness  and  because  the 
filiform  may  be  tied  into  the  urethra  imtil,  by  repeated  dilatations,  a 
sufficient  size  shall  have  been  attained  to  insure  the  patency  of  the 
stricture. 

CATHETERS 

A  good  catheter  must  be  smooth  both  inside  and  out,  boilable  and 
durable.  Two  special  features  of  importance  are  the  "round-edo-ed" 
or  "velvet"  eye,  now  universally  employed,  and  the 
funnel  end,  which  is  universally  em- 
ployed in  Europe  and  conspicuously 
neglected  by  American  manufactur- 
ers. 

Soft-rubber  Catheters.  —  These 
commend  themselves  for  general  use 
by  their  flexibility.  Of  all  urethral 
instruments  they  can  be  passed  the 
most  gently.  The  choice  of  sizes  lies 
between  15  and  20  French.  An  in- 
strument larger  than  the  latter  size 
is  unnecessary,  while  most  instru- 
ments of  the  former  size  have  so 
Fig.  7.  — Woven  small  a  caliber  that  they  transmit  fig.  8.— Double-e]> 
ETEHs.^^  "  fluids  very  slowly,  and  are  obstructed     bowed  Catheteb. 

by  even  a  small  amount  of  viscid  pus 
or  blood  clot.     Yet  these  smaller  instruments  pass  more  comfortably 
through  a  sensitive  urethra. 

Woven  Olivary  Catheters  (Fig.  Y). — These  are  useful  to  pene- 
trate a  small  orifice  (stricture,  spasm),  while  woven  elbowed  catheters 
introduced  with  the  point  directed  upward,  ride  over  obstacles  on  the 
urethral  floor  (false  passage,  hypertrophied  prostate).     Woven  doiible- 

'The  rough  eye  of  the  tunneled  sound  scratches  the  urethra,  slips  with  difficulty 
over  the  filiform,  ami  bends  or  even  breaks  this  in  the  urethra,  complicating  the 
already  difficult  situation  by  the  addition  of  a  false  passage  or  a  foreign  body. 


24 


URETHRAL  INSTRUMENTS:  THEIR  ASEPSIS 


elbowed  catlieters  (Fig.  8)  ride  over  certain  prostatic  obstacles  wliicli 
the  single-elbowed  instruments  will  not  surmount.  Woven  olive-tipped 
elhoived  catheters  (Fig.  7)  combine  tlie  advantages  of  the  olivary  and 
elbowed  instruments,  and  are  more  generally  useful  than  either.  But 
sometimes  a  spasmodic  or  congested  urethra  admits  a  blunt  instrument 
more  readily  than  an  olive-tipped  one,  just  as  occasionally  a  straight 
instrument  may  pass  where  an  elbowed  one  will  not.     "Natural  curve" 


7 


Fig.  9. — Natural  Curve  Catheter. 


Fig.  10. — GuTON 
Obtur.'^.tor. 


catheters  (Fig.  9)  are  more  generally  useful  than  any  other  type  of 
woven  catheters.  I  employ  them  almost  exclusively.  Since  woven  in- 
struments have  a  relatively  larger  caliber  than  soft-rubber  ones,  they 
may  be  employed  in  rather  small  size  (15  to  IT  French),  and  one  should 
possess  very  small  woven  instruments  (10  French)  to  pass  a  tight 
stricture  or  a  greatly  congested  prostate. 

Indwelling-  Catheters — These  are  not  necessary  instruments,  and 
since  they  have  to  be  made  of  a  relatively  perishable  mixture  they  are 


URETHRAL  INSTRUMENTS 


25 


usually  stiff  and  useless  before  the  occasion  for  their  use  arises.  Indeed 
the  indwelling  catheter  usually  irritates  the  male.  It  is  therefore  used 
almost  exclusively  in  women. 

For  such  prostatic  obstacles  as  cannot  be  sumiounted  by  even  the 
"natural  curve"  catheter,  various  ingenious  devices  have  been  employed. 
The  silver  catheter,  with  a  long,  "prostatic"  curve,  is  a  dangerous  in- 
strument in  inexpert  hands,  which  may  rarely  be  passed  with  safety, 
even  by  an  expert,  more  than  once  or  twice  in  a  given  case.  A  very 
satisfactory  substitute  is  the  elbowed  or  Benique  curved  obturator  of 
Guyon  (Fig.  10).  This,  when  slipped  into  a  rubber  or  woven  catheter, 
converts  it  temporarily  into  a  stiff  instrument,  with  the  great  advantage 
that  the  obturator  may  be  withdrawn,  leaving  an  in- 
dwelling, soft  catheter  in  the  urethra. 

Silver  Catheters. — Silver  catheters,  tunneled  or 
threaded,  for  filiforms,  are  useful  in  an  emergency  to 
relieve  stricture  retention.  The  silver  catheter  curved 
like  a  sound,  that  is  found  in  every  pocket  case  of  instru- 
ments, is  inferior  in  every  respect,  except  that  of  port- 
ability, to  a  woven  instrument. 

SYRINGES  AND  NOZZLES 

One  of  the  most  difficult  to  obtain  of  all  urological 
instruments  is  a  good  syringe  of  large  capacity. 

The  Janet  Syringe  (Fig.  11). — This  is  an  excellent 
instrument.  These  syringes  hold  125  to  150  c.c.  of 
fluid.  When  not  in  constant  use,  the  rubber  piston 
must  be  kept  out  of  the  barrel. 

Quarter-ounce  Blunt-nozzled  Glass  Syringes. — 
These  are  necessary  for  injections  into  the  anterior 
urethra. 

Instillators. — Instillators  of  the  Keyes  ^  pattern 
(Fig.  12  j,  as  at  present  constructed,  consist  essentially  of  small-caliber, 
short-curve  silver  catheters,  with  the  eye  in  the  tip.  These  are  fitted  to 
thread  or  slip  on  any  hypodermic  syringe.  The  instruments  are  thus 
readily  sterilized  and  portable.  The  straight  part  of  the  shaft  should 
be  six  inches  long,  in  order  to  keep  its  outer  end  clear  of  the  glans  penis. 


Fig.  11. — Janet 
Sykinge. 


ANTERIOR   URETHRAL   IRRIGATION 

The  apparatus  for  anterior  uretlival  irrigation  consists  of  a  tank 
(preferably  of  glass,  and  so  hung  that  it  may  l)e  readily  raised  and 

^The  Ultzmann  syringe,  of  which  the  Keyes  is  a  modification,  is  a  very  clumsy 
instrument.  The  Guyon  instillator,  a  capillary  woven  catheter,  has  never  found  favor 
in  this  country.  Modifications  of  the  Keyes  instrument  have  been  niade  by  Cabot, 
Bangs,  and  others. 


26  URETHRAL  INSTRUMENTS:  THEIR  ASEPSIS 

lowered),  a  connecting  tube,  a  nozzle,  and  means  of  interrupting  tlie 
flow  of  fluid  through  the  tube. 

The  tank  forms  part  of  the  urological  equipment.     Of  nozzles  and 
interrupters  there  is  a  great  variety.     The  simple,  blunt-pointed  glass 


Fig.  12. — Keyes  Instillator. 

nozzle  and  a  cut-off  with  protecting  bell,  form  the  most  familiar  appara- 
tus. 

UKETHROSCOPES,    CYSTOSCOPES,    ETC. 

A  description  of  urethroscopes,  cystoscopes,  etc.,  is  more  appro- 
priately reserved  for  a  special  chapter.  The  same  is  true  of  the  opera- 
tive armamentarium. 


ASEPSIS  IN  URETHRAL  EXAMINATION 

However  infected  the  bladder  into  which  a  catheter  or  sound  is  to 
enter,  that  catheter  must  be  scrupulously  aseptic.  The  days  when  sur- 
geons may  joke  about  the  old  gentleman  who  keeps  his  catheter  inside 
his  hat  and  spits  on  it  by  way  of  lubrication  are  past.^  Even  when  the 
bladder  is  infected  asepsis  is  imperative,  to  prevent  an  increase  of  that 
infection. 

The  asepsis  of  catheterism,  using  the  term  broadly  to  cover  every 
passage  of  an  instrument  into  the  urethra,  implies  three  requirements, 
viz. : 

1.  Asepsis  of  the  physician's  hands. 

2.  Antisepsis  of  the  patient's  urethra. 

3.  Asepsis  of  the  instrument  introduced. 

*Yet  such  old  gentlemen  are  still  encountered  in  practice.  But  the  apparent 
immunity  which  some  of  them  enjoy  is  due  in  part  to  the  fact  that  their  bladders 
are  already  so  severely  infected  that  a  little  saliva  makes  them  no  worse.  And 
though  their  immunity  may  for  a  time  prevail,  in  the  end  they  become  more  and 
more  infected  and  die  of  sepsis.  The  need  for  scrupulous  asepsis  is  not  because 
every  dirty  catheterism  causes  infection,  but  because  a  single  dirty  catheterism  may 
cause  infection  of  the  gravest  sort. 


ASEPSIS  IN  URETHRAL  EXAMINATION  27 

ASEPSIS    OF    THE    PHYSICIAN'S   HAITDS 

It  is  not  possible  to  require  of  the  physieian  about  to  pass  a  catheter 
that  he  sterilize  his  hands  as  if  for  a  surgical  operation,  or  wear  sterile 
rubber  gloves.  Such  cleanliness  is  only  required  for  such  prolonged 
and  delicate  operations  as  cystoscopy.  But  the  physician's  hands  should 
be  well  washed  with  soap  and  water,  and,  having  washed  his  hands,  the 
physician  sliould  act  as  though  they  were  still  dirty;  i.  e.,  he  should  not 
touch  that  part  of  the  instrument  that  is  to  enter  the  deep  urethra. 
This  is  a  simple  rule,  a  necessary  rule,  a  universal  rule.  The  last  three 
inches  of  the  instrument  sliould  not  he  touched  hy  anything  except^ 
sterilized  lubricant  from  the  time  it  is  sterilized  until  it  enters  the 
urethra. 

ANTISEPSIS   OF    THE    PATIENT'S   URETHEA 

The  Uninflamed  Urethra. — It  has  been  amply  proven  ^  that,  though 
the  posterior  urethra  is  sterile,  the  normal  anterior  urethra  may  harbor 
quite  an  indefinite  number  and  variety  of  pathogenic  microorganisms. 
But,  on  account  of  the  mechanical  cleansing  of  the  urinary  stream, 
these  are  almost  exclusively  confined  to  the  balanitic  portion  of  the 
canal.  Yet  it  is  not  unusual  to  find  bacteria  in  the  bulb  of  the  unin- 
flamed urethra,  though  it  is  most  unusual  not  to  find  them  in  the 
terminal  inch  (p.  166). 

Moreover,  the  preputial  cavity  swarms  with  bacteria.  Hence  has 
arisen  the  practice  of  washing  the  glans  penis  and  flushing  the  terminal 
inch  of  the  urethra  with  boric  acid  solution  before  introducing  any  in- 
strument. Though  such  washing  and  flushing  is  scarcely  more  effective 
than  that  of  the  urinary  stream,  and  might,  therefore,  be  omitted,  except 
in  case  the'  danger  of  infection  is  unusually  great,  i.  e.,  in  cystoscopy, 
catheterism  for  aseptic  retention,  and  tying  in  an  indwelling  catheter, 
perfect  technic  requires  that  this  washing  and  flushing  always  pre- 
cede introduction  of  urethral  instruments  of  whatever  description. 

The  Inflamed  Urethra. — When  the  urethra  is  acutely  inflamed,  the 
passage  of  instruments  is  permissible  only  for  the  cure  of  that  inflam- 
mation, or  for  the  relief  of  retention  of  urine.  In  either  event  the 
mechanical  damage  done  by  any  added  manipulations  outweighs  their 
virtue.  No  special  effort  should  therefore  be  made  to  clean  the  canal : 
the  glans  and  meatus  should  be  well  washed. 

Chronic  urethritis  is  no  bar  to  the  passage  of  instruments.  These 
may  be  used  either  for  the  treatment  of  urethritis  or  for  the  diagnosis 
or  treatment  of  coexisting  conditions. 

*  Lustf^arten  and  Mannaberjr,  Viertdjahressclirift  f.  J.  Derm.  u.  Si/ph.,  1887; 
Eovsing,  "Die  Blasenentzundungen, "  1890;  Wassermann  and  Petit,  Guyon's  Jnnakr 
1891,  ix,  371;  Melchior,  "Cystite  et  infection  urinaire,"  Paris,  1895. 


28  UEETHRAL  INSTRUMENTS:  THEIR  ASEPSIS 

In  the  former  case  the  instrumentation  (catheterism)  habitually 
carries  with  it  its  own  antisepsis  (injection). 

In  the  latter  event  (passage  of  sound,  cystoscope,  etc.),  not  only  may 
this  instrumentation  not  directly  imply  antisepsis,  but  it  may  directly 
imply  considerable  trauma  to  an  infected  canal.  Therefore  it  is  neces- 
sary to  precede  the  instrumentation  by  a  soap-and-water  and  bichlorid 
wash  of  the  glans  and  adjoining  tissues,  and  a  thorough  irrigation  of 
the  meatus,  and  even,  in  some  cases,  of  the  whole  urethra,  with  silver 
nitrate  1 :  4,000,  or  oxycyanid  of  mercury  1 :  4,000.  But  the  urologist 
must  not  confide  too  much  in  what  is  at  best  but  a  superficial  and  in- 
complete antisepsis  of  the  anterior  urethra.  The  danger  of  infection 
is  far  more  closely  related  to  clumsiness  or  roughness  in  passing  the  in- 
strument than  to  preliminary  urethral  antisepsis.  Every  surgical  opera- 
tion must  he  cleanly ;  hut  every  urethral  manijjulation  must  also,  and 
ahove  all,  he  gentle. 

The  dangers  of  urethral  instrumentation  are  local  (exacerbation  of 
urethritis,  prostatic  or  periurethral  abscess),  and  chiefly  to  be  avoided 
by  discretion  in  the  choice  of  and  gentleness  in  the  passage  of  the  in- 
strument; or  general  (urethral  chill,  systemic  gonorrhea,  urinary  sep- 
ticemia), and  chiefly  to  be  avoided  by  antisepsis,  to  a  less  degree  by 
gentleness. 

This  antisepsis,  of  which  the  principles  and  practice  are  discussed  in 
Chapter  XXXVII,  consists  in : 

Hexamethylenamin  before, 

Gentleness  during,  and 

Local  antisepsis  after  instrumentation. 

The  hexamethylenamin  may  often  be  omitted  with  impunity,  and;, 
since  it  implies  administration  of  the  drug  for  forty-eight  hours  before 
instrumentation,  it  is  often  neglected.  But  there  is  no  excuse  for  neg- 
lecting to  be  gentle  or  for  omitting  some  form  of  antisepsis  after  instru- 
mentation. Even  when  the  temper  of  the  urethra  is  well  known  the 
omission  of  a  postinstrumental  antisepsis  may  unexpectedly  excite  a 
sharp  chill. 

The  usual  postinstrumental  antisepsis  consists  of  an  instillation  of 
nitrate  of  silver  or  an  irrigation  with  some  silver  salt  or  with  perman- 
ganate of  potassium. 

ASEPSIS   OF   THE   INSTRUMENT 

In  any  case,  the  instrument  introduced  must  be  aseptic.  By  this 
we  mean  that  the  whole  instrument  must  be  rendered  aseptic,^   and 

^  The  flaming  of  a  metal  instrument  whereby  the  beak  and  shaft  are  sterilized, 
but  the  dirty  handle  remains  uncleansed  would  be  perfectly  permissible  were  it  not 
a  dangerous  habit  to  permit  the  least  relaxation  of  asepsis.  Moreover,  the  con- 
venience of  flaming  compared  to  boiling  is  quite  imaginary. 


URETHRAL  INSTRUMENTS :  THEIR  ASEPSIS  29 

must  so  remain  except  for  its  contact  with  the  physician's  hands,  which, 
as  already  stated,  should  not  touch  its  terminal- three  inches. 
This  asepsis  implies  four  conditions: 

1.  Aseptic  lubrication. 

2.  Antisepsis  immediately   after  using. 

3.  Aseptic  preservation. 

4.  Antisepsis  before  using. 

Lubrication. — The  lubricant  employed  for  urethral  instruments 
should  be  soluble  in  water.  Oily  lubricants,  such  as  vaselin  or  olive  oil, 
may  be  perfectly  sterilized  by  boiling,  but  they  can  only  be  removed  from 
the  instrument  with  great  difficulty,  if  at  all.  Hence,  an  instrument 
covered  by  an  oily  lubricant  is  much  more  difficult  to  resterilize  than 
one  which  is  mechanically  clean.  Albarran  has  shown  that  a  clean 
catheter  may  be  sterilized  by  boiling  for  ten  minutes,  while  an  oily 
catheter  must  be  boiled  half  an  hour. 

Among  the  substances  in  common  use  as  lubricants  may  be  men- 
tioned glycerin  and  boroglycerid.  Guyon  uses  a  mixture  of  equal  parts 
of  water,  glycerin,  and  soap  powder.  Various  combinations  of  Iceland 
moss,  sterilized  in  formalin,  are  sold  under  different  trade  names.  But 
the  best  lubricant  I  know  has  the  following  formula,  modified  by  Dr.  E. 
Wood  Ruggles : 

Dissolve  1  cm.  of  oxycyanid  of  mercury  in  200  c.c.  of  hot  sterile 
water;  add  35  c.c.  of  glycerin  and  water  enough  to  make  350  c.c.  Let 
this  mixture  cool ;  then  add  10  to  15  gm.  of  powdered  gum  tragacanth. 
Let  this  stand  until  it  becomes  a  homogeneous  mass,  a  process  which 
takes  several  days,  but  may  be  hastened  by  occasional  stirring  to  break 
up  the  lumps.  The  amount  of  tragacanth  employed  depends  upon  the 
consistence  of  this  substance,  which  varies  considerably. 

This  lubricant  may  be  put  up  in  sterile  paint  tubes.  Its  quality  de- 
pends upon  the  employment  of  precisely  the  right  amount  of  tragacanth. 

The  Instrument. — The  practice  of  asepsis  for  urethral  instruments  is 
approximately  that  of  general  surgery,  and  requires  that: 

1.  The  instrument  should  be  so  constructed  as  to  be  readily  cleansed. 
It  should  be  as  free  as  possible  from  joints,  crannies,  etc.  It  should 
be  in  good  condition,  free  from  rust  or  cracks. 

2.  It  should  be  sterilized  by  boiling.  Strong  (almost  saturated) 
sodium  chlorid  solution  is  less  destructive  than  plain  water.^ 

3.  It  should  be  washed  clean  and  sterilized  immediately  after  using, 
kept  sterile  (if  possible),  and  resterilized  immediately  before  using. 

4.  Instruments  for  use  in  ''pus  cases"  should  be  kept  entirely  dis- 
tinct from  those  for  use  upon  "clean  cases." 

^  Krotoszyner  (Medical  News,  1904,  Ixxv,  406)  makes  this  suggestion  and  also 
suggests  a  saturated  solution  of  ammonium  sulphate  for  woven  instruments. 


30  URETHRAL  INSTRUMENTS :  THEIR  ASEPSIS 

Unfortunately  tlie  one  instrument  tliat  is  the  least  subject  to  any  of 
these  rules,  viz.,  the  cystoscope,  is  the  very  instrument  that  preeminently 
requires  sterilization.  The  special  measures  required  for  sterilization 
of  cystoscopes  are,  therefore,  considered  elsewhere  (p.  51). 

All  other  instruments  should  be  subjected  to  the  following: 

1.  Soap  and  water  wash,  inside  and  out,  immediately  after  using. 
Then  rinse  in  water  and  boil  for  at  least  fifteen  minutes  in  strong  salt 
solution. 

2.  Keep  the  instruments  in  an  instrument  case,  the  interior  of 
which  is  kept  at  least  relatively  clean  by  formalin  (trioxym ethylene) 
pastilles,  or  a  formalin  lamp. 

3.  Unless  the  instrument  has  been  recently  used  and  its  asepsis 
assured,  always  resterilize  by  boiling  for  fifteen  minutes  immediately  be- 
fore using. 

4.  Use  a  separate  set  of  catheters  at  least  for  gonorrheal  cases. 
The  special  variations  and  precautions  in  the  technic  of  sterilization 

required  by  various  instruments  are  the  following : 

Dilators  and  Other  Complex  Instruments. — Dilators,  urethro- 
tomes, and  such  complex  instruments  should  be  made  of  pure  nickel; 
otherwise  it  is  almost  impossible  to  keep  them  from  rusting.  If  nickel- 
plated,  they  must  be  sterilized  like  the  cystoscope  (p.  51). 

Woven  Instruments. — It  is  the  accepted  tradition  that  woven  in- 
struments cannot  be  boiled,  and  it  is  current  practice  to  sterilize  them 
by  formalin  vapor.  But  I  have  for  several  years  been  boiling  all  my 
woven  instruments,  and  can  assert  that  they  stand  boiling  perfectly 
well  if  they  are  of  standard  French  manufacture  (any  one  of  half  a 
dozen  firms)  and  if  their  sterilization  is  surrounded  with  a  few  simple 
precautions. 

When  a  woven  instrument  is  hoiled,  its  varnish  becomes  utterly  soft, 
and  therefore  cracks  if  any  other  instrument  rests  upon  it,  or  if  it  is 
bent  before  it  has  cooled.  Therefore  it  must  lie  perfectly  straight  in 
the  sterilizer,  touching  neither  the  sides  nor  the  ends  of  this,  and  with 
no  other  instrument  resting  upon  it.  More  important  still,  after  the 
instrument  has  been  boiled  it  must  not  be  touched  until  it  has  been 
cooled  off,  either  by  lifting  it  from  the  water  on  an  automatic  platform 
or  by  pouring  in  cold  sterilized  water. 

ASEPSIS  OF  OTHER  INSTRUMENTS  AND  OF   SOLUTIONS 

In  order  to  permit  clean  urethral  work,  the  wall  tanks,  syringes,  and 
other  containers,  as  well  as  the  solutions,  must  be  sterilized  quite  as  care- 
fully as  the  urethral  instruments  themselves. 

Tanks,  Syringes,  Etc. — All  containers  are  best  sterilized  by  boiling 
immediately  before  each  clinic  or  office  hour.  Wall  tanks  may,  however, 
be  left  filled  with  an  antiseptic  solution  between  times.    It  is  necessary 


URETHRAL  INSTRUMENTS :  THEIR  ASEPSIS  31 

to  have  at  hand  a  pan  of  boric  acid  solution  in  which  to  cool  sounds 
after  boiling,  and  to  rinse  instruments  that  have  been  sterilized  by 
formalin.  It  is  my  custom  to  keep  all  syringes,  hypodermic  needles, 
mixing  rods,  instillator  catheters,  in  a  10  per  cent  formalin  solution, 
supersaturated  with  borax.^ 

It  is  peculiarly  important  that  all  containers  should  be  kept  from 
any  contact  with  urine.  The  measuring  glass  for  urine  should,  there- 
fore,  be  of  a  peculiar  shape,  readily  distinguishable  from  that  employed 
for  the  solutions. 

Solutions. — All  solutions  should  be  made  up  fresh,  warm,  and  asep- 
tic. The  chemicals  are  kept  in  a  certain  stock  (preferably  solid)  form 
(p.  211),  and  the  water  must  be  both  sterile  and  warm.  The  urologist 
should  have  two  boilers,  containing  a  gallon  or  two  apiece,  each  one  of 
which  should  be  boiled  every  alternate  day,  so  that  hot  and  cold  sterile 
water  are  at  hand  to  be  mixed  in  any  desired  proportion. 

For  him  who  depends  upon  a  central  supply  of  sterilized  water  (e.  g., 
a  boiler  in  the  operating  room),  it  is  more  convenient  to  keep  cold  sterile 
water  in  a  glass  reservoir  and  hot  water  in  a  metal  reservoir,  covered 
with  asbestos. 

SUMMARY   OF   INSTRUMENTAL  ASEPSIS 

For  Cystoscopes. — Cabinet  containing  formalin  lamp  and  desicca- 
tion apparatus.     Clean  well  before  and  after  sterilization. 

For  Other  Instruments. — Boil  for  fifteen  minutes.  Use  soluble 
lubricants,  and  boil  again  after  use.     Keep  in  formalin  cabinet. 

For  Solutions. — Hot  and  cold  boiled  water  in  boilers  or  tanks. 
Containers  boiled  daily.  Mixing  rods,  syringes,  etc.,  boiled  and  kept  in 
sterile  solutions. 

^  Steel  instruments  do  not  rust  in  this  solution  if  enough  borax  is  kept  in  it 
actually  to  supersaturate  it  and  leave  a  little  undissolved  at  the  bottom  of  the  jar. 
As  the  borax  dissolves  very  slowly  what  may  appear  enough  when  the  solution  is 
first  made  up  proves  insufficient  a  day  or  two  later. 


CHAPTER    IV 

THE  PASSAGE   OF   URETHRAL  INSTRUMENTS 

The  successful  introduction  of  an  instrument  into  the  urethra  de- 
pends upon  the  skill  of  the  operator  and  his  comprehension  of  the 
obstacles  that  may  defeat  the  operation. 

ANATOMY  OF  THE  URETHRA 


The  urethra  is  the  outlet  of  the  bladder.  It  commences  at  the  blad- 
der neck,  but  embryologically  and  anatomically  that  part  of  the  floor 
of  the  bladder  known  as  the  trigone  (i.  e.,  the  triangular  space  between 
the  orifices  of  the  ureters  and  the  urethra)  belongs  to  the  urethra,  and 
will  be  so  considered. 

The  urethra  tunnels  the  upper  part  of  the  prostate,  perforates  the 
triangular  ligament,  and  terminates  at  the  end  of  the  penis.     Its  outer 


Fig.  13. — Sagittal  Section  throtjge 
Glans  and  Fossa  Naviculaeis. 
(Cruveilhier.) 


Fig.  14. — Transverse  Sec- 
tion OF  THE  Penis.  (Cru- 
veilhier.) 


opening  is  known  as  the  meatus,  or  the  meatus  urinarius.  The  urethra 
is  divided  naturally  into  two  parts,  the  anterior  and  the  posterior 
urethra,  by  the  triangular  ligament,  the  anterior  urethra  lying  external 
to  the  anterior  layer  of  that  structure,  and  the  posterior  urethra  being 
the  continuation  of  the  canal  backward  into  the  bladder.  The  anterior 
or  spongy  portion  of  the  urethra  is  again  subdivided  into  four  parts,  the 
navicular  (or  the  fossa  navicularis.  Fig.  13),  penile  (Fig.  14),  scrotal, 
and  bulbous  or  bulboperineal.  The  posterior  urethra  is  subdivided 
into  the  membranous,  the  prostatic,  and  the  trigonal  portions.  It  is 
much  more  accurate  to  speak  of  a  lesion,  such  as  a  foreign  body  or  a 

32 


ANATOMY  OF  THE  URETHRA  33 

stricture,  as  being  at  the  penoscrotal  angle  or  in  the  bulb,  than  to  say 
it  lies  at  a  depth  of  4  or  6  inches,  for  not  only  does  the  length  of  the 
urethra  vary  according  as  the  penis  is  erect  or  flaccid  and  in  disease 
(hypertrophy  of  the  prostate),  but  the  urethral  length,  the  urinary  dis- 
tance, varies  widely  in  different  healthy  individuals  (p.  37).  The 
urethra  is  always  a  closed  canal  throughout  its  whole  course,  except  when 
distended  by  some  foreign  substance. 

The  mucous  membrane  of  the  urethra  consists  of  a  layer  of  epithe- 
lium, of  which  the  superficial  cells  are  squamous  in  the  navicular  and 
prostatic  regions  and  columnar  elsewhere,  on  a  connective-tissue  base- 
ment substance  particularly  rich  in  elastic  fibers  to  allow  for  the  great 
distensibility  of  the  canal. 


THE   ANTERIOR   URETHRA 

In  the  anterior  urethra  the  mucous  membrane  is  surrounded,  except 
in  the  fossa  navicularis,  by  a  very  thin  longitudinal  layer  of  unstriped 
muscle  fibers  (in  direct  continuity  with  the  inner 
fibers  of  the  prostate),  and  these  are  in  turn  sur- 
rounded by  a  circular  layer  of  unstriped  muscle. 
These  circular  fibers  are  so  few  around  the  spongy 
urethra  that  their  very  existence  was  denied  by 
Sappey.  Finally,  the  anterior  urethra  is  sur- 
rounded from  triangular  ligament  to  meatus  by  the 
corpus  spongiosum,  except  for  the  half  inch  nearest 
the  bladder,  where  the  corpus  spongiosum  fails  to 
cover  the  roof  of  the  urethra  and  is  enlarged  below 
into  the  huJh. 

Crypts  and  Glands— In  the  roof  of  the  fossa     ^'''Ml^o7^'^''^Cvi- 
navicularis  lies  the  lacuna  magna  (Fig.  15),  a  sim-  veilhier.) 

pie  pocket  in  the  mucous  membrane  with  its  orifice 
toward  the  meatus,  and  consequently  open  to  entrap  small  instruments. 
This  lacuna  varies  greatly  in  size  in  different  persons,  being  some- 
times entirely  absent,  and  occasionally  running  as  far  back  as  the 
triangular  ligament,  forming  the  so-called  double  urethra  (q.  v.).  A 
few  other  smaller  lacunae  lie  along  the  roof  of  the  penile  urethra. 
The  gla^ids  of  the  urethra,'^  to  be  distinguished  from  the  lacunae,  are 
of  the  compound  racemose  type,  of  very  small  caliber,  lined  with  a 
cylindrical  epithelium.  They  lie  chiefly  on  the  roof  of  the  anterior 
urethra,  and  are  more  numerous  in  its  deeper  parts.  They  are  also 
found  on  the  -roof  of  the  membranous  urethra.  In  some  instances 
they  pierce  the  sheath  of  the  C()rj)us  spongiosum  and  extend  for  some 

^Paschkis,  Monatsbericht  f.  Urol,  190:5,  No.  6;  and  Lichtenberg,  Beitr.  z.  HistoL, 
etc.,  d.   Urogenital  Kanals,  etc.,  Wiesbaden,  1906. 


34  THE  PASSAGE  OF  URETHRAL  INSTRUMENTS 

distance  within  it — an  important  fact  in  relation  to  organic  stricture 
of  the  canal,  since  these  glands  convey  the  products  of  urethral  inflam- 
mation into  the  corpus  spongiosum  and  so  involve  it  in  the  subsequent 
cicatrization.  Coivpers  glands  are  two  small,  rovind,  lobular  bodies, 
each  about  the  size  of  a  cherry  stone,  lying  just  behind  the  bulb  of  the 
urethra  in  the  muscle  between  the  layers  of  the  triangular  ligament. 
Their  ducts  open  on  the  floor  of  the  bulbous  urethra. 

The  color  of  the  membrane  is  pale  pink.  In  rest  its  walls  are  in 
contact,  obliterating  the  cavity  of  the  canal,  so  that  a  cross-section  pre- 
sents a  transverse  slit  instead  of  an  opening  (Fig.  18). 

The  anterior  urethra  is  called  the  external  urinary  tract,  and  the 
canals  and  reservoirs  beyond  the  internal  urinary  tract,  for  the  anterior 
urethra  is  in  free  communication  with  the  surface  of  the  body  and  har- 
bors all  the  microorganisms  that  may  lie  thereon.  As  a  general  thing 
it  does  this  with  perfect  impunity.  Its  flora  include  the  bacteria  found 
upon  the  skin;  notably  pseudodiphtheria  bacilli  and  staphylococcus 
albus  (p.  166).  Such  bacteria  as  flourish  normally  in  the  anterior  ure- 
thra, being  constantly  washed  out  by  the  urine,  and  entering  only 
through  the  meatus  (except  under  pathological  conditions),  are  most 
numerous  in  the  fossa  navicularis,  and  indeed  are  usually  found  only  in 
that  region. 

THE   POSTERIOR   URETHRA 

The  posterior  urethra,  extending  from  the  anterior  layer  of  the 
triangular  ligament  to  the  bladder,  presents  many  notable  points  of 
contrast  with  the  anterior  urethra.  The  canal  is  no  longer  surrounded 
by  erectile  tissue,  and,  indeed,  it  could  scarcely  become  erect,  for 
whereas  the  anterior  urethra  is  freely  movable  with  the  penis,  the  pos- 
terior urethra  possesses  a  fixed  curve — of  which  later.  Moreover,  the 
posterior  urethra  is,  in  its  normal  state,  entirely  free  from  the  bacteria 
harbored  by  the  anterior  urethra ;  it  is  the  lowest  section  of  the  aseptic 
internal  urinary  tract. 

The  posterior  urethra  is  divided  into  the  membranous  and  the  pros- 
tatic urethra,  and  the  trigone  of  the  bladder. 

The  Membranous  Urethra. — Of  all  parts  of  the  canal  the  membra- 
nous urethra  is  the  most  fixed,  running,  as  it  does,  from  the  aperture  in 
the  anterior  layer  of  the  triangular  ligament  to  the  aperture  in  the  pos- 
terior layer.  Its  mucous  membrane,  though  of  a  darker  color  and  much 
more  sensitive,  does  not  differ  in  structure  from  that  of  the  anterior 
urethra.  This  in  turn  is  surrounded  by  a  thin  layer  of  unstriped  muscle, 
but  instead  of  being  sheathed  in  the  corpus  spongiosum,  it  is  embedded 
in  the  voluntary  muscle  that  fills  the  space  between  the  two  layers  of 
the  triangular  ligament.  This  muscle  has  had  special  names  given  to 
difi'erent  portions  of  it  by  Guthrie,  Miiller,  Wilson,  and  others,  but  it 


ANATOMY  OF  THE  URETHRA 


35 


may  be  considered  clinically  as  one  muscle,  the  constrictor  or  compressor 
uretlirae,  the  cut-off  muscle,  the  external  or  voluntary  sphincter  of  the 
bladder.  The  last  term  best  expresses  its  function.  It  is  the  muscle 
by  which  the  outflow  of  urine  from  the  bladder  is  voluntarily  opposed. 
It  may  suffer  from  spasm,  and  so  not  only  prevent  urination,  but  also 
present  a  serious  obstacle  to  the  introduction  of  instruments.  This  is 
spasmodic  stricture  {q.  v.). 

The  Prostatic  Urethra. — The  prostatic  urethra  tunnels  the  pros- 


FiG.  16. — Lower  Part  of  the  Male  Bladder,  with  the  Beginning  of  the  Urethra. 
Exposed  by  incising  the  anterior  wall  and  laying  it  open.  3,  ureter;  4,  opening  of  the 
ureter;  2,  vas  deferens;  9  verumontanum ;  7,  center  of  trigone;  8,  section  of  prostate;  10, 
orifice  of  the  common  ejaculatory  duct;  11,  opening  of  utricle,  12,  mouths  of  prostatic 
gland  ducts;  1,  interureteric  fold.     (Henle.) 


tate,  sometimes  barely  covered  by  that  organ  above,  sometimes  deeply 
embedded  in  it  (Fig.  18).  It  is  fixed  only  where  it  joins  the  mem- 
branous urethra.  It  is  fusiform  in  shape,  being  closed  internally  by 
the  internal  or  involuntary  sphincter  of  the  bladder.  Into  it  the  ducts 
of  the  sexual  organs  empty.  It  is  lined  by  squamous  epithelium  like 
that  of  the  bladder,  and  is  liable  to  great  deformity  and  obstruction 
by  prostatism.  Upon  its  floor  rises  a  little  mass  of  erectile  tissue,  the 
verumontanum,  or  caput  gallinaginis,  the  anterior  slope  of  M-hich  is 
hollowed  out  into  a  little  cavity,  the  sinus  pocularis  or  uiricle  (Fig.  16). 
The  prostatic  ducts  open  upon  the  floor  of  the  urethra  on  each  side  of 
the  verumontanum.  The  ejaculatory  ducts  usually  open-  in  the  sinus 
pocularis  or  on  its  edges. 


36 


THE  PASSAGE  OF  URETHRAL  INSTRUMENTS 


Fig.  17. — Sagittal  Section  of  a  Frozen  Male  Subject.  The  small  intestine  is  removed. 
1,  peritoneum;  6,  opening  of  the  ureters;  8,  internal  sphincter;  9,  external  sphincter, 
with  the  compressor  urethras  muscle;  10,  dorsal  vein  of  the  penis;  15,  bulbocavernosus 
muscle;  16,  bulb  of  the  urethra;  17,  sphincter  ani;  21,  utricle;  24,  isthmus  of  prostate; 
29,  seminal  vesicles.     (Henle.) 


THE  SPHINCTERIC  MECHANISM 

The  urinary  tract,  like  the  intestinal  tract,  possesses  two  sphincters, 
an  internal  sphincter  of  unstriped  muscle  and  an  external  sphincter  of 
striped  muscle  fiber  (Fig.  17). 

The  External  or  Voluntary  Sphincter — This  is  the  constrictor  or 
compressor  urethrae,  mentioned  above.  It  surrounds  the  membranous 
urethra  almost  to  the  apex  of  the  prostate.  On  the  upper  surface  of 
the  urethra  the  fibers  of  the  compressor  continue  back  for  a  centimeter 
or  more  over  the  anterior  surface  of  the  prostate. 

The  Internal  Sphincter. — The  internal  sphincter  surrounds  the 
neck  of  the  bladder  and  spreads  out  fanlike  throughout  the  trigone  of 


ANATOMY  OF  THE  URETHRA  37 

the  bladder,  reaching  the  ureteral  mouths,  and  thus  forming  a  con- 
necting band  between  the  ureters  and  the  urethra. 

THE    VESICAL    TRIGONE 

Kalisher  ^  has  plainly  shown  that  the  trigone,  i.  e.,  the  triangular 
portion  of  the  bladder  floor  lying  between  the  orifices  of  the  urethra  and 
of  the  ureters,  belongs  to  the  urethra  and  not  to  the  bladder.  The 
trigone  develops  with  the  urethra  and  the  ureters,  while  the  bladder 
is  developed  from  the  allantois.  The  muscle  of  the  trigone  is  the  in- 
ternal sphincter.  The  mucous  membrane  contains  papillae  and  a  few 
scattered  glands  (which  the  bladder  proper  does  not).  The  circulation 
of  the  lower  ends  of  the  ureters,  the  trigone,  and  the  prostatic  urethra 
is  derived  from  the  inferior  vesical  artery.  The  lymphatics  of  the  tri- 
gone are  more  numerous 
than  they  are  elsewhere  in 
the  bladder,  and  are  in  di- 
rect communication  with 
those  of  the  posterior  ure- 
thra. 

Length. — The  length  of  

the  urethra,   varying  as   it 

A         '      A'ff    '      i-  '    A'    ' A      1  Fig.  18. — Longitudinal  Section  of  Urethra,     a, 

aoes  m  ainerent  maiViaualS  ^^  g^^j  ^  represent  the  prostatic,  membranous,  and 

and   in  the  same   individual  spongy  portions  of  the  urethra.     (Thompson.) 

with  erection  of  the  penis 

and  hypertrophy  of  the  prostate,  may  be  set  down  as  averaging  20.5  cm. 
(8:j  inches),-  and  varying  in  different  normal  individuals  from  18  to  23 
cm.  {7^  to  8f  inches).  The  posterior  urethra  is  usually  5.5  cm.  (2^ 
inches)  long — 2.5  cm.  (1  inch)  to  the  membranous  portion,  3  cm.  (1^ 
inches)  to~  the  prostatic — and  the  anterior  urethra  15  cm.  (6  inches) 
long,  subdivided  as  follows:  2.5  cm.  (1  inch)  to  the  navicular  region, 
6.25  cm.  (24-  inches)  to  the  penile,  3  cm.  (l-j-  inches)  to  the  scrotal,  and 
3  cm.  flj-  inches)  to  the  bulboperineal. 

Diameter. — The  diameter  of  the  nomial  urethra  (Fig.  18)  varies 
even  more  than  the  length — it  has  been  estimated  at  from  2  to  6  lines. 
A  fair  average  is  not  larger  than  0.75  cm.  (0.3  inch)  ;  about  Xo.  27, 
French  scale.  But,  whatever  its  size,  the  urethra  is  not  a  tube  of  uni- 
form caliber  from  end  to  end.  It  has  naturally  four  points  of  physio- 
logical narrowing:  the  first  at  the  meatus,  the  second  at  the  peno- 
navicular  junction,  the  third  beginning  about  half  an  inch  back  of  this, 
and  becoming  most  pronounced  at  about  the  penoscrotal  junction.  Tbe 
fourth  and  fifth  con.strictions  are  the  voluntary  sphincter  (the  entire 
membranous  urethra)  and  the  internal  involuntary  sphincter  (the  neck 

•■^"Die  Musculatur  ties  Damraes, "  p.  151. 
'Kejes,  Am.  J.  Med.  Sci.,  1S98,  cxvi,  125. 


38  THE  PASSAGE  OP  URETHRAL  INSTRUMENTS 

of  the  bladder).  Of  these  five  narrow  points,  three,  it  will  be  ob- 
served, are  organic  and  situated  in  the  anterior  urethra,  while  the  other 
two  are  muscular  and  situated  in  the  posterior  urethra.  The  muscular 
constrictions  are  widely  dilatable,  and  the  caliber  of  the  canal  is  deter- 
mined bj  the  meatus,  normally  the  narrowest  point.  Hence  the  caliber 
of  the  urethra  is  the  caliber  of  its  normal  meatus.  The  penonavicular 
and  penoscrotal  constrictions  are  usually  mere  irregularities  in  the 
canal,  besides  which  there  are  often  lesser  contractions  at  various  points, 
making  the  urethra,  when  distended,  not  a  smooth,  evenly  calibrated 
tube,  but  a  very  irregular  one.  The  three  chief  dilatations  of  the  normal 
canal  are  the  fossa  navicularis,  which  is  situated  just  inside  the  meatus ; 
the  bulbous  urethra,  occupying  a  position  immediately  in  front  of  the 
triangular  ligament,  and  the  prostatic  urethra  (Fig.  18).  Of  these  the 
second  is  the  largest. 

Curve. — In  relation  to  these  variations  of  caliber  Guyon's  observa- 
tions upon  the  relative  qualities  of  the  urethral  roof  and  floor  are  of  in- 
terest far  more  from  a  practical  than  from  a  theoretical  point  of  view.^ 
His  observations  may  be  classified  as  follows : 

1.  The  roof  of  the  urethra  (when  the  penis  is  erect)  forms  an  unin- 
terrupted curve  from  the  fossa  navicularis  to  the  bladder. 

2.  All  the  variations  of  caliber,  except  the  fossa  navicularis,  are 
produced  at  the  expense  of  the  floor,  which  is,  in  consequence,  very  ir- 
regular.^ 

3.  The  mucous  membrane  of  the  roof  is  more  closely  adherent  to 
the  subjacent  structures  than  that  of  the  floor. 

4.  The  mucous  membrane  of  the  floor  of  the  urethra  is  much  more 
elastic  than  that  of  the  roof. 

Therefore,  not  only  is  the  floor  of  the  urethra  more  irregular  than 
the  roof,  but  its  irregularities  may  be  increased  with  much  greater  facil- 
ity by  any  object  introduced  into  the  canal,  as  well  as  by  disease.  In 
other  words,  instruments,  especially  if  small  and  rigid,  may,  with  their 
points,  furrow  the  floor  of  the  urethra  until,  finally,  they  become  pock- 
eted (usually  in  the  bulb),  and  so  are  brought  to  a  full  stop,  while  an 
instrument  whose  point  impinges  always  on  the  roof  avoids  these  ob- 
structions and  glides  easily  into  the  bladder.  Therefore  this  eminent 
French  surgeon  has  termed  the  roof  the  surgical  wall  of  the  urethra — 
the  wall,  namely,  which  is  the  guide  to  instruments  entering  the  bladder. 
That  fistulae  and  false  passages  almost  always  occur  in  the  floor  and 
lateral  walls,  and  that  the  orifice  of  a  stricture  is  usually  nearer  the  roof 
than  the  floor — these  two  facts  make  the  roof  the  surgical  wall  in  dis- 
ease even  more  than  in  health. 


*" Lemons,"   ii,  309    et  seq. 

^Though  not  absolutely  accurate,  both  of  these  observations  are  clinically  cor- 


rect. 


THE  CURVE  OF  URETHRAL  INSTRUMENTS  39 

THE  CURVE  OF    URETHRAL   INSTRUMENTS 

From  these  considerations  it  follows  that  the  curve  of  the  urethra 
is  the  curve  of  its  roof.  Now  the  entire  anterior  urethra  is  freely  mov- 
able with  the  penis,  and  can  be  made  to  assume  any  curve.  JSTot  so  the 
posterior  canal.  The  membranous  urethra,  bound  tightly  at  its  ex- 
tremities by  the  two  layers  of  the  triangular  ligament,  is  the  real  fixed 
point  of  the  urethra,  and  runs  at  a  distance  of  from  1  to  2  cm.  (f  to  f 
inch)  below  the  symphysis  pubis.  In  front  of  this  the  bulbous  urethra 
tends  slightly  upward  because  of  the  tension  of  the  suspensory  ligament 
and  of  the  skin  and  fascia,  while  a  similar  elevation  is  given  to  the  pros- 
tatic urethra  behind  by  the  puboprostatic  ligaments  and  the  anterior 
fibers  of  the  levator  ani  muscles.  Thus  is  formed  the  so-called  fixed 
curve  of  the  urethra — not  a  true  fixed  curve,  for  by  depression  of  the 
bulbous  and  the  prostatic  urethrae  to  the  level  of  the  membranous  por- 
tion it  can  be,  and  often  is,  transformed  into  a  straight  line — as  when  a 
sound  is  pushed  home  until  its  shaft  is  in  line  with  the  patient's  body, 
or  when  straight  metal  instruments  are  introduced.  The  curve  varies  ^ 
slightly  in  different  persons,  and  in  the  same  person  at  different  periods 
of  life,  being  shorter  and  sharper  in  the  child,  longer  in  the  old  man. 
An  enlarged  prostate  lengthens  the  curve. 


PHYSIOLOGY  OF  THE  URETHRA 

Sensibility. — Under  normal  conditions  the  sensibility  of  the  an- 
terior urethra  is  slight,  although  it  is  exquisitely  sensitive  when  in- 
flamed.    The  prostatic  urethra  may  be  excessively  sensitive,  while  the 

^  The  proper  average  curve,  as  recognized  by  Sir  Charles  Bell  and  insisted  on  by 
Sir  Henry  Thompson  and  Dr.  Van  Buren — the  one  which  will  mathematically  accord 
with  the  greatest  number  of  urethrae — is  that  of  a  circle  8.125  cm.  in  diameter;  and 
the  proper  length  of  arc  of  such  a  circle,  to  represent  the  subpubic  curve,  is  that 
subtended  by  a  chord  of  6.875  cm.  long.  An  instrument  made  with  a  short  curve  of 
this  sort  will  readily  find  its  way  through  the  normal  urethra  into  the  bladder  without 
the  employment  of  any  force.  It  is  very  desirable  that  instruments  intended  for 
habitual  use  should  be  so  constructed,  inasmuch  as  many  of  the  difficulties  of 
catheterism  are  due  to  a  defective  curve  in  the  instrument  employed.  The  defect  most 
frequently  encountered  is  too  great  straightness  of  the  last  half  inch — a  deviation 
of  the  curve  at  its  most  important  point.  In  an  instrument  properly  made  it  will  be 
found  that  a  tangent  to  the  nxis  of  the  curve  at  its  extremity  will  intersect  the  pro- 
jected axis  of  the  shaft  at  a  little  less  than  a  right  angle.  If  tlie  curve  comprised  only 
a  quarter  of  the  circle,  the  tangent  would  meet  the  i)rojectcd  shaft  at  a  riglit  angle; 
but  instruments  made  a  little  longer,  as  they  are  usually  found,  invariably  have 
the  last  part  of  the  curve  tilted  off  into  a  faulty  direction,  making  tlie  angle  between 
a  tangent  to  the  axis  of  the  curve  at  this  point  and  the  projected  axis  of  the  shaft 
obtuse,  and  falling  within   the   right  angle. 


40  THE  PASSAGE  OF  URETHRAL  INSTRUMENTS 

membranous  portion  of  the  canal  is  alM^ays  somewhat  sensitive.  Indeed, 
tlie  first  passage  of  an  instrument  through  this  part  of  the  urethra  of  a 
nervous  individual  is  attended  not  only  by  pain,  but  also  bj  a  decided 
shock.  He  becomes  pale  and  nauseated,  may  even  faint,  if  not  already 
in  a  recumbent  position;  while  the  recorded  deaths  ensuing  upon  this 
simple  maneuver,  though  few,  attest  its  severity.^  This  acute  sensi- 
bility becomes  rapidly  deadened,  unless  the  canal  is  inflamed,  so  that 
after  a  few  repetitions  the  operation  is  attended  by  no  shock  and  but 
little,  if  any,  pain. 

This  urethral  shock  is  an  element  in  some  cases  of  so-called  urinary 
fever.  It  is  rarely  the  sole  cause  of  death,  but  often  contributory  by 
its  reflex  action  upon  diseased  kidneys,  and  tingeing  the  frankly  septic 
cases  with  a  neurotic  element  not  otherwise  to  be  explained.  Moreover, 
it  contributes  to  the  elucidation  of  the  mystery  of  urethral  neuralgia 
and  urethral  spasm,  and  is  doubtless  concerned  in  the  explanation  of 
the  fact  that  the  form  of  septicemia  known  as  urinary  fever,  so  common 
after  injury  to  the  deeper  portions  of  the  canal,  becomes  less  and  less 
to  be  feared  the  farther  forward  the  injury,  and  is  unheard  of  when 
the  trauma  affects  only  the  balanitic  portion  of  the  canal. 

Mobility. — The  muscles  of  the  penis  and  urethra  are  thrown  into 
action  only  during  urination  or  erection  and  emission,  and  their  func- 
tions are  therefore  more  fitly  described  under  these  titles.  A  few  words 
concerning  the  cut-off  muscle  may  not  be  amiss  in  this  place.  Besides 
its  most  important  function  of  preventing  the  urine  from  escaping  from 
the  bladder  by  an  effort  of  the  will  and  of  cutting  off  the  stream,  it  pre- 
sents several  interesting  physiological  characteristics.  The  urethra  in 
front  of  the  cut-off  muscle  swarms  with  bacteria,  while  all  beyond  is 
genn-free.  This  is  so,  not  because  the  muscle  presents  an  impassable 
barrier,  for  it  does  not.  When  violently  contracted  it  doubtless  does 
form  an  insurmountable  barrier  to  bacterial  invasion,  but  its  periods 
of  contraction,  like  those  of  the  external  sphincter  ani — to  which  it  bears 
a  close  resemblance — are  comparatively  infrequent  and  of  short  dura- 
tion. Its  normal  tone,  however,  is  sufficient  to  make  the  channel  a 
narrow  and  difficult  one,  readily  cleansed  of  any  chance  invader  by 
the  periodical  outflow  of  urine.  It  is  suggestive,  moreover,  that  the  cut- 
off muscle  surrounds  the  most  sensitive  part  of  the  urethra.  Hence 
the  cause  of  spasm  in  this  muscle,  whether  acute  from  some  local  or 
general  shock,  or  chronic  as  a  speciflc  evidence  of  a  neurotic  habit,  is 
not  far  to  seek. 

*  They  are  doubtless  due  to  status  lympJiaticus. 


TECHNIC   OF  PASSAGE  OF   SOFT  URETHRAL   INSTRUMENTS      41 


TECHNIC    OF    THE    PASSAGE    OF    SOFT    URETHRAL 
INSTRUMENTS 

Antiseptic  Preparations — The  instruments  are  sterilized,  tlie  opera- 
tor's hands  washed  and  the  meatus  and  glaus  cleansed,  as  described 
in  Chap'ter  III, 

Lubrication. — The  object  of  lubricating  a  urethral  instrument  is 
not  to  make  the  instrument  slippery,  hut  to  let  it  slip  through  the  meatus. 
A  small  dab  on  each  lip  of  the  meatus  is  all  that  is  needed,  and  this  is 
best  applied,  not  by  greasing  the  whole  shaft  of  the  instrument,  but  by 
transferring  a  bit  of  lubricant  to  its  tip,  and  with  it  smearing  the  lips 
of  the  meatus. 

Position  of  the  Patient. — The  patient  should  lie  flat  upon  his  back 
for  the  first  instrumentation,  since  this  sometimes  causes  marked  nerv- 
ous shock.  But  for  subsequent  operations  he  may  assume  any  con- 
venient position. 

Introduction  of  the  Instrument. — The  catheter  is  readily  intro- 
duced as  far  as  the  bulbous  urethra.  Up  to  this  point  the  urethra 
offers  no  obstruction,  unless  the  meatus  is  unusually  small  (p.  251). 
But  unless  the  penis  is  held  at  right  angles  to  the  patient's  body,  the 
bend  of  the  urethra  at  the  point  of  attachment  of  the  suspensory  liga- 
ment (just  back  of  the  penoscrotal  angle)  offers  a  slight  resistance. 

At  the  junction  of  the  bulbous  and  the  membranous  portions  of  the 
urethra  the  catheter  encounters  the  compressor  urethrae  muscle.  This 
muscle  may  present  a  scarcely  perceptible  obstacle  or  it  may  be  excited 
to  reflex  spasm  of  such  intensity  as  to  prevent  the  entrance  of  the 
catheter. 

Method  of  Overcoming  Spasm  of  the  Compeessoe. — When  the 
advance  of  the  catheter  is  obstructed  by  the  compressor  urethrae,  the 
tip  of  the  instrument  may  lie  just  within  the  grasp  of  the  outer  fibers 
of  this  muscle  or  it  may  pass  down  into  the  pocket  of  the  bulb. 

The  first  maneuver  to  overcome  this  obstacle  is  to  crowd  the  catheter 
gently  but  firmly  into  the  urethra  and  hold  it  there  for  half  a  minute. 
On  releasing  the  catheter  it  either  springs  back  or  remains  in  place.  If 
it  springs  back  it  may  be  taken  for  granted  that  the  tip  of  the  instru- 
ment is  pocketed  in  the  bulb,  and  does  not  present  at  the  opening  of  the 
muscle ;  it  must  then  be  removed  and  another  instrument  selected.  But 
if  the  catheter  docs  not  spring  back  it  may  again  be  crowded  against  the 
muscle  ir  the  hope  that  a  slight  advance  has  been  made  and  that  fur- 
ther pushing  will  finally  overcome  the  spasm. 

The  second  maneuver  is  to  select  an  instrument  that  will  present  its 
point  accurately  at  the  orifice  of  the  muscle  and  have  sufficient  rigidity 
to  overcome  the  spasm.     The  best  instrument  for  this  purpose  is  the 


42 


THE  PASSAGE  OF  URETHRAL  INSTRUMENTS 


"natural  curve"  woven  catheter.  It  usually  slips  readily  into  the  pos- 
terior urethra. 

The  third  maneuver  is  to  aid  the  passage  of  the  woven  catheter 
by  gentle  pressure  upon  the  floor  of  the  bulbous  urethra  with  a  finger 
against  the  perineum,  while  with  the  other  hand  the  catheter  is  gently 
pushed  forward. 

The  fourth  inaneuver  is  to  replace  the  woven  instrument  by  a  metal 
one,  and  to  pass  this  according  to  the  rules  laid  down  below.  If  prop- 
erly performed,  this  maneuver  always  succeeds. 

Method  of  Passijs^g  the  ISTeck  of  the  Bladder. — When  a  flexible 
catheter  has  passed  the  compressor  muscle  of  a  normal  urethra  it  enters 
the  bladder  without  further  difiiculty.  But  if  the  catheter  stops  we 
know  that  its  point  has  caught  in  the  floor  of  the  prostatic  urethra  in 
front  of  the  internal  sphincter.  It  may  be  lifted  out  by  pressure  with 
a  finger  introduced  into  the  rectum. 


TECHNIC  OF  THE  PASSAGE  OF  METAL  INSTRUMENTS 


The  penis,  properly  cleansed  (p.  27)  and  with  foreskin  drawn,  is 
held  at  right  angles  to  the  patient's  body  while  the  lips  of  the  meatus  are 
lubricated  by  a  touch  with  the  tip  of  the  instrument. 

The  shaft  of  the  instrument  is  held  over  the  fold  of  the  gToin,  its 
handle  nearly  in  contact  with  the  skin,  from  which  latter  (the  integTi- 


FiG.  19. — Introduction  of  Sound. 


TECHNIC  OF  THE  PASSAGE  OF  METAL  INSTRUMENTS        43 

ment,  first  of  the  groin  and  then  of  the  abdomen)  it  is  not  to  be  removed 
until  the  point  of  the  instrument  is  about  to  enter  the  membranous  Dor- 
tion  of  the  urethra.  The  instrument,  at  first  held  along  the  groin,  with 
point  high  and  handle  low  (Fig.  19),  is  introduced  at  the  meatus,  and 
the  penis  molded  up  over  it.  It  is  not  pushed  into  the  urethra,  but 
the  urethra  is  made  to  swallow  the  instrument,  as  it  were. 

When  the  curve,  and  perhaps  an  inch  of  the  shaft,  have  disappeared 
within  the  meatus,  the  handle  of  the  instrument  is  swept  around  over 
the  surface  of  the  belly,  so  as  to  lie  exactly  over  the  linea  alba,  parallel 


Fig.  20. — Introduction  of  Sound. 


with  it,  and  still  close  to  the  integument.  The  whole  shaft  of  the  in- 
strument is  now  to  be  gently  pressed  toward  the  patient's  feet,  being 
still  kept  close  to  and  parallel  wnth  the  surface  of  the  belly  (the  penis, 
meanwhile,  being  lightly  grasped  behind  the  corona  glandis  and  held 
steady). 

The  point  of  the  instrument  may  be  followed  with  the  little  finger 
of  the  hand  which  manages  the  penis,  and,  when  it  gets  fairly  past  the 
penoscrotal  angle,  the  whole  scrotum,  with  the  testicles  and  penis,  should 
be  largely  seized  with  the  hand  and  pressed  against  the  pul)is,  with 
slight  upward  traction  (Fig.  20).  The  point  may  now  be  felt  to  settle 
down  and  adapt  itself  to  the  sul)pul)ic  curve,  after  whicli  the  weight  of 
the  instrument,  properly  directed,  should  carry  it  into  the  bladder. 

As  soon  as  the  curve  lies  well  against  the  symphysis,  the  scrotum, 
testicles,  and  penis  should  be  dropped;  the  hand  which  held  them  takes 


44 


THE  PASSAGE  OF  URETHRAL  INSTRUMENTS 


the  instrnment,  steadies  it  in  the  median  line,  and  gradually  carries  the 
shaft  away  from  the  abdomen  (Fig.  21),  making  the  handle  describe 
the  arc  of  a  circle,  and  depressing  the  shaft  between  the  thighs  until  it 
lies  nearly  in  the  same  plane  with  them.  No  pushing  movement  should 
be  imparted  to  the  instrument  during  this  time.  The  handle  is  made 
to  describe  the  arc  of  a  circle,  and  in  a  healthy  urethra  the  point  cannot 
go  astray.  While  the  instrument  is  being  depressed  between  the  thighs, 
the  free  hand  is  employed  in  pressing  down  upon  the  mons  veneris  and 
the  root  of  the  penis  (Fig.  21),  to  stretch  the  suspensory  ligament — a 
point  of  importance  to  the  easy  introduction  of  an  instrument. 


Fig.  21. — Introduction  of  Sound. 


The  instrument  should  be  withdrawn  with  the  same  deliberation  and 
care  with  which  it  is  introduced.  ]^o  traction  is  needed.  The  motions 
used  in  introduction  are  simply  reversed.  The  handle  of  the  instrument 
is  lightly  caught,  and  without  traction  made  to  describe  the  arc  of  a 
circle  until  it  touches  the  abdomen  over  the  linea  alba.  It  is  then  car- 
ried around  to  the  groin,  and,  by  a  tilting  motion,  unhooked  from  the 
urethra,  ending  exactly  where  it  commenced  along  the  groin,  the  handle 
low,  the  point  high. 

The  first  principle  of  instrumentation  in  the  urethra  is  to  avoid  the 
use  of  force.  Even  in  a  healthy  subject  the  beak  of  the  instrument  may 
become  pocketed  in  the  floor  of  the  urethra.  It  is  to  avoid  this  that  up- 
ward traction  on  the  scrotum  and  penis  is  made,  whereby  the  beak  of  the 
instrument  is  held  in  contact  with  the  roof  of  the  urethra,  the  surgical 


TECHNIC  OF  THE  PASSAGE  OF  METAL  INSTRUMENTS        45 

wall,  until  it  gently  slides  of  its  own  weight  into  the  bulb  and  impinges 
against  the  triangular  ligament.  Here  the  beak  of  the  instrument 
naturally  sinks  into  the  sinus  of  the  bulb,  and  ceases  to  advance.  IsTow 
it  is  that  the  operator,  by  pressing  downward  the  mons  veneris,  tilts  the 
instrument  so  that  its  beak  touches  the  roof  of  the  canal,  and  slides 
gently  into  the  membranous  urethra,  the  cut-off  muscle  relaxing  before 
it.  But  often  the  beak  is  not  so  readily  liberated.  That  it  is  still 
caught  in  the  bulb  may  be  known  by  the  bulging  out  of  its  curve  in  the 
perineum  as  the  shaft  is  being  depressed  between  the  thighs,  and  by  the 
rebound  of  the  handle  when  liberated.  The  obstacle  is  overcome  by 
gently  maneuvering  the  point  of  the  instrument,  by  partial  withdrawal 
and  reintroduction,  or  by  slight  depression  of  the  beak,  then  lifting  it 
over  the  obstacle  with  a  finger  in  the  perineum,  at  the  same  time  press- 
ing down  upon  the  shaft  of  the  instrument  to  make  its  point  sweep 
the  roof  of  the  canal.  The  dangerous  tour  de  maitre  ^  should  never  be 
tried,  nor  any  force  used  in  the  manipulations  at  this  point,  as  a  false 
passage  is  easily  made  here  and  under  these  very  circumstances.  The 
depression  of  the  handle  of  the  instrument  alone  is  capable  of  exerting 
enormous  power.  The  sound  represents  a  lever  of  the  first  order,  and 
the  surgeon  has  the  long  arm. 

With  a  little  patience  a  suitable  instrument  will  always  pass  into  the 
bladder  unless  there  is  a  stricture.  When  the  point  has  traversed  the 
membranous  urethra  it  must  continue  on  freely  if  the  prostate  is  normal. 
The  so-called  spasm  of  the  neck  of  the  bladder  does  not  exist  as  an  ob- 
struction to  the  passage  of  instruments. 

The  sound  need  only  be  introduced  far  enough  to  bring  its  greatest 
diameter  into  the  membranous  urethra.  This  is  accomplished  when  the 
shaft  has  been  depressed  almost,  but  not  quite,  to  the  plane  of  the  body. 
To  pass  it  farther,  so  as  to  straighten  out  the  prostatic  urethra,  is  un- 
necessary, painful,  and,  in  certain  cases,  dangerous. 

Instruments  small  enough  to  engage  in  the  sinuses  of  Morgag-ni  are 
not  used  in  the  healthy  canal.  Instrumentation  in  morbid  conditions 
will  be  detailed  in  connection  with  the  different  diseases  requiring  it. 

The  cystoscope  and  the  stone  searcher  are  introduced  in  the  manner 
above  described ;  but  the  depression  of  the  handle  is  carried  far  enough 
to  permit  the  angle  of  the  instrument  to  slip  over  the  bladder  neck,  an 
occurrence  sig-nalized  by  a  distinct  jerk  on  the  part  of  the  instrument. 

The  sensation  experienced  by  a  healthy  urethra  is  that  of  hot  points 
pricking  the  canal  along  the  part  being  traversed  by  the  instrument. 
As  this  enters  the  membranous  urethra,  a  desire  to  urinate  begins  to  be 

^The  tour  de  moUre  consists  in  introilueing  a  sound  with  the  shaft  between  the 
patient's  legs  until  the  point  is  arrested  at  the  bulb;  then  tlie  handle  is  rapidly  made 
to  describe  a  semicircle  until  it  reaches  a  vertical  position,  when  it  is  at  once 
depressed  between  the  thighs.     This  is  brilliant  but  dangerous. 


46  THE  PASSAGE  OF  URETHRAL  INSTRUMENTS 

felt,  which  increases  as  the  prostate  and  the  neck  of  the  bladder  become 
distended  bj  the  instrument,  so  that  the  patient  sometimes  believes  the 
urine  is  flowing  awaj,  in  spite  of  the  surgeon's  assertions  and  his  own 
observation  to  the  contrary.  JSTausea,  and  even  syncope,  may  occur 
as  the  instrument  distends  the  prostate,  especially  on  the  first  introduc- 
tion in  sensitive  young  people.  Occasionally  distention  of  the  prostatic 
sinus  produces  a  partial  erection. 

If  the  patient  faints,  the  instrument  should  be  withdrawn  at  once 
and  the  legs  elevated,  while  the  head  is  hung  over  the  edge  of  the  lounge 
upon  which  he  lies.  The  facility  with  which  this  may  be  done,  if  neces- 
sary, is  one  of  the  reasons  for  placing  the  patient  on  his  back  for  his  first 
catheterization. 

The  more  serious  conijjUcations  of  catheterization,  such  as  false  pas- 
sages, urethral  fever,  etc.,  will  be  considered  in  the  succeeding  chapters. 
Ordinarily  speaking,  none  of  these  complications  need  be  expected  to 
follow  the  gentle  passage  of  a  clean  instrument  into  a  urethra  which  is 
neither  inflamed  nor  lacerated;  but  in  order  to  avert  the  possibility  of 
cystitis  or  chill  it  is  safe  to  terminate  every  catheterization  or  sounding 
by  an  instillation  along  the  whole  urethra  of  a  few  drops  of  silver- 
nitrate  solution  (1 :  1,000),  unless  some  other  solution  is  used  as  a  part 
of  the  treatment,  or  the  temper  of  the  urethra  is  well  known. 


CHAPTER   V 

CYSTOSCOPY 

Cystoscopy  is  inspection  of  the  interior  of  the  bladder.  The  instru- 
ment employed,  the  cystoscope,  consists  essentially  of  a  tube  or  tele- 
scope, through  which  the  operator  looks,  and  a  source  of  illumination. 
Modem  cystoscopes  are  of  two  types,  viz. : 

1.  The  closed  tube  cystoscope,  employed  with  water  in  the  bladder 
(Leiter,  ISTitze,  Albarran,  Brunner,  Boisseau  du  Rocher,  etc.). 

2.  The  open  tube  cystoscope,  employed  with  air  in  the  bladder 
(Kelly,  Buys). 

The  Closed  Tube. — This  instrument,  originally  devised  by  Leiter 
and  Nitze,  modified  and  improved  by  many  urologists  and  instrument 
makers,  is  almost  universally  employed  at  the  present  time.  It  is  fully 
described  below. 

The  Open  Tube. — For  use  in  women  Howard  Kelly  devised  a 
straight  open  tube  cystoscope,  to  be  introduced  with  the  patient  in  the 
knee-chest  position  and  illumined  by  light  reflected  from  a  head  mirror. 

Luys  has  adapted  this  instrument  for  use  in  the  male,  by  introduc- 
ing it  on  a  flexible  obturator,  and  adding  a  suction  tube  to  keep  the 
bladder  dry,  so  that  the  knee-chest  position  is  not  required. 

Although  the  inventors  of  these  instruments  employ  them  with  great 
skill  their  range  of  vision  is  much  more  limited  than  that  of  cystoscopes 
of  the  closed  tube  type,  and  I  have  never  employed  them. 


THE  CYSTOSCOPE 

In  its  present  form  it  consists  of  two  parts,  the  sheath  and  the  tele- 
scope. 

The  Sheath. — The  cystoscope  sheath  (Fig.  22)  is  a  metal  tube  that 
serves  three  purposes : 

1.  It  conveys  an  electric  light  into  the  bladder. 

2.  It  permits  irrigation  of  the  bladder  before,  during  and  after 
the  cystoscopy. 

3.  It  admits  a  telescope  through  which  the  interior  of  the  blad- 
der is  observed. 

The  Telescope. — The  cystoscopic  telescope  permits  the  observer  to 

47 


4B 


THE  CYSTOSCOPE 


49 


inspect  the  interior  of  tlie  bladder,  to  insert  catheters  or  bougies  into 
the  nreters,  and  to  manipulate  wires,  snares,  pincers,  etc.,  for  the 
purpose  of  performing  certain  operations  within  the  bladder. 

The  lenses  of  the  telescope  may  be  arranged  in  three  ways,  viz. : 

1.  The  prismatic,  or  indi- 
rect-vision telescope  (Fig.  23) 
looks  out  at  right  angles  to  the 
shaft  of  the  sheath.  The  win- 
dow through  which  it  looks 
may  be  on  the  concavity 
(ISTitze  type)  or  the  convexity 
of  the  sheath.  The  N^itze  type 
enjoys  a  more  general  popu- 
larity, but  admirable  instru- 
ments are  made  in  both  types. 

Each  has  its  advantages.     The      t.      oo     t  t,  ^ 

.    °  Fig.  23. — Lenses   of    Prismatic    Cystoscope. 

prism    naturally    inverts    the  (After  Young.) 

image  (Fig.  24)  but  a  system 

of  lenses  has  been  devised  to  correct  this  inversion  without  sacrificing 

light. 

2.  The  direct-vision  telescope  (Fig.  2-i)  looks  directly  out  through 
the  end  of  the  sheath.  It  has  the  same  restricted  field  of  vision  as  the 
open  tube  instruments.  This  type  of  telescope,  though  never  generally 
employed  abroad,  still  enjoys  considerable  popularity  in  this  country. 
But  recent  improvements  in  the  prismatic  telescope  make  it  the  better 

implement   from    every 
standpoint. 

3.  The  retrogTade 
telescope  looks  back 
toward  the  observer. 
Such  an  instrument  is 
calculated  to  give  an 
exceptionally  good  view 
of  the  bladder  neck  and 
adjacent  bladder  wall. 
But  though  Schlagint- 
weit  appears  to  have  solved  the  problem  of  retrograde  vision  in  his  cys- 
toscope, here  again  the  prismatic  instrument  leaves  little  to  be  desired. 
For  through  it,  by  the  employment  of  different  degrees  of  distention,  all 
parts  of  the  bladder  may  be  viewed. 

The  cystoscope  is  spoken  of  as  catheterizing,  operating,  or  examin- 
ing, to  accord  with  the  presence  or  absence  of  tunnels,  attached  to  the 
telescope  for  the  admission  of  ureter  catheters  or  other  instruments. 
The  lever  devised  by  Albarran  for  the  manipulation  of  these  implements 


Fig. 


24. — Lenses    of    Direct     Vision     Cystoscope. 
(After  Young.) 


50  CYSTOSCOPY 

forms  an  essential  part  of  the  telescope  to  a  catheterizing  or  operating 
cystoscope.     Special  telescopes  are  made  for  cystoscopic  photography. 
The  Choice  of  an  Instrument. — The  following  considerations  may 
help  in  the  choice  of  an  instrument: 

1.  Its  maker  should  be  accessible.  The  importation  of  cystoscopes 
from  distant  countries  involves  harassing  delay,  expense  and  mis- 
understanding, when  repairs  are  required. 

2.  The  instrument  should  be  simple,  its  sheath  round,  its  lamp 
"cold,"  and  preferably  with  tungsten  filament,  its  lenses  corrected  for 
inversion  of  image,  its  caliber  not  more  than  24  F.  It  should  admit  two 
7  F.  ureter  catheters. 

A  similar  instrument  for  use  in  children,  of  18  F.  caliber,  admits 
one  5  F.  catheter. 

Beyond  this  it  is  impossible  to  specify.  Each  year  brings  forth 
some  new  improvement  or  some  change  in  fashion. 

Substitutes  for  the  Cystoscope. — While  the  cystoscope  was  ap- 
proaching its  present  state  of  perfection  several  instruments,  entitled 
"urine  separators"  were  devised  by  Harris,  Cathelin  and  Luys,  as  sub- 
stitutes for  the  ureter  catheterism.  But  perfection  of  the  cystoscope 
has  eliminated  them  from  the  field. 


PREPARATION  FOR  CYSTOSCOPY 

INSTRUMENTS  REQUIRED 

Cystoscopes. — As  already  described. 

Ureter  Catheters. — The  best  sizes  are  5,  6  and  7  F.     The  catheter 
should  have  at  least  two  eyes.     The  Albarran  flute-tip  catheter  (Fig. 
25)  catches  the  urine  better  than  any  other,  but  it  is 
well  to  have  a  few  olivary-tip  catheters  for  entering 
b...l|  rebellious  ureters.     In  order  to  estimate  how  far  the 

catheter  enters  the  ureter,  as  well  as  for  the  purpose 
■*  of  distinguishing  right  from  the  left,  it  is  wise  to  use 

an  unmarked  catheter  for  one  ureter  and  for  the 
other  an  instrument  marked  off  in  centimeters  (Fig. 
25). 

Cystoscopic    Accessories. — Always    have    every- 
thing   iu    duplicate :    cystoscope,    lamps,    connecting 
Fig.  25. -Flute-     ^^^.jg     ^^^^ 

TIPPED  Catheter.  '  j?  t  •    i. 

EyesatA,  B,  c.  Source  of  Light.— If  no  electric  current  is  acces- 

sible one  must  use  dry  cells  or  a  storage  battery. 
Ordinarily  it  is  more  convenient  to  depend  upon  a  rheostat  attached  to 
an  electric  light  fixture.  But  when  this  is  iu  use  one  must  never  forget 
the  danger  of  "grounding"  by  wet  floors  and  pipes. 


PREPARATION  FOR  CYSTOSCOPY  51 

"When  employing  the  high  frequency  current  for  intravesical  opera- 
tions it  is  safer  to  derive  the  cystoscopic  current  from  a  storage  battery. 

Source  of  Irrigation.^At  home  one  uses  a  wall  tank  full  of  cold 
sterile  water  (neither  heat  nor  chemicals  being  required)  ;  elsewhere  a 
Janet  piston  syringe. 

For  Anesthesia  and  Lubrication. — For  more  than  five  years  I  have 
combined  anesthesia,  antisepsis  and  lubrication  by  the  injection  into 
the  urethra  of  the  lubricant  described  on  p.  29,  to  which  is  added  5 
per  cent  alypin  or  2  per  cent  cocain.  The  latter  is  the  better  anes- 
thetic, and  so  little  of  it  is  absorbed  that  it  is  quite  free  from  the  very 
real  danger  attached  to  the  use  of  cocain  solutions  in  the  urethra. 

This  lubricant  may  be  introduced  through  a  catheter  as  it  is  gradu- 
ally withdrawn,  by  means  of  a  .small  glass  syringe. 

Other  cystoscopists  employ  10  per  cent  novocain  solution,  5  per  cent 
alypin  solution,  or  alypin  tablets  introduced  by  a  special  instrument. 
Cocain  solutions  should  never  be  used  because  of  the  recognized  danger 
of  fatal  poisoning  therefrom. 

Urethral  Instruments. — One  may  require  a  blunt-end  bistoury  to  cut 
the  meatus,  bougies  or  sounds  to  dilate  a  stricture,  "natural  curve" 
woven  catheters,  10  F.  (to  place  in  the  bladder  with  the  ureter  cathe- 
ter), or  16  F.  (to  empty  the  bladder  after  the  cystoscopy). 

Other  Accessories — "Visible"  ureter  catheters  for  radiography,  so- 
lutions and  syringes  for  the  injection  of  phenolsulphonephthalein,  collar- 
gol,  morphin,  etc.,  sterile  test  tubes  or  bottles,  appropriately  labeled, 
for  the  collection  of  specimens  of  urine,  basins,  rubber  apron,  urine 
glasses,  etc.,  should  be  provided,  according  to  the  requirements  of  the 
individual. 

Sterilizing  Accessories — Green  soap,  bichlorid  solution,  sterile 
wipes,  sheets,  towels,  leglets,  gown,  gloves,  and  cap. 

STERILIZATION 

Instruments. — Most  of  the  instruments  and  accessories  used  in 
cystoscopy  may  be  sterilized  by  boiling  or  in  the  autoclave.  Barney 
has  even  made  the  very  ingenious  suggestion  that  the  ureter  catheters  be 
boiled  in  lengths  of  rubber  tubing  and  be  attached  to  the  cystoscope 
encased  in  these,  and  so  fed  into  the  cystoscope,  protected  from  contact 
even  with  the  operator's  hand,  not  to  mention  his  head. 

But  the  cystoscope  itself  may  not  be  boiled.  It  must  be  sterilized 
(after  due  cleansing  with  soap  and  thou  alcohol)  in  a  solution  of  car- 
bolic acid,  alcohol  or  cyanato  of  mercury  or  in  formalin  vapor. 

Such  being  the  case,  and  inasmuch  as  the  patient's  urethra  cannot 
be  rendered  fully  aseptic,  T  prefer  to  deal  in  antiseptics.  Accordingly 
my  cystoscopes  with  their  accessory  cords,  rheostats,  etc.,  are  kept  sterile 


52  CYSTOSCOPY 

in  a  cabinet  in  which  a  formalin  lamp  is  lighted  for  at  least  half  an 
liour  before  each  cystoscopy. 

Ureter  catheters  are  cleansed  inside  and  out  in  running  water 
immediately  after  use.  Then  they  lie  several  hours  in  1 :  5,000  bichlorid 
solution.  Then  they  are  sterilized  inside  and  out  in  a  small  formalin 
sterilizer.  Then  they  are  kept  in  the  formalin  cabinet  with  the  cysto- 
scopes.  This  may  seem  an  excessive  sterilization;  and,  indeed,  it  pro- 
hibits cultivation  of  bacteria,  unless  the  urine  is  directly  implanted 
from  the  catheter  into  the  culture  medium.-^  But  contemplate  the 
dangers  of  tuberculosis  inoculation  from  unclean  catheters ! 

The  Patient  and  the  Operator. — The  penis  or  vulva  should  be 
cleansed  with  soap  and  water  and  bichlorid  solution  and  surrounded 
by  a  perforated  sterile  sheet,  as  though  for  a  surgical  operation.  The 
urethra  should  be  well  irrigated  with  boric  acid  solution  unless  the 
antiseptic  anesthetic  lubricant  is  employed. 

The  operator  should  be  sterilized  as  for  a  surgical  operation. 

PKEPARATION  OF  THE  PATIENT 

Preparation  before  Examination — A  preliminary  course  of  bladder 
irrigation,  urotropin  medication,  or  toughening  the  urethra  by  the  pas- 
sage of  sounds,  is  appropriate  in  many  instances. 

The  operation  may  usually  be  performed  in  the  physician's  office 
or  at  the  clinic.  But  enfeebled  or  nervous  patients,  especially  nervous 
women,  will  appreciate  being  examined  at  home  or  in  a  hospital.  And 
for  them  a  preliminary  hypodermic  injection  of  morphin  is  peculiarly 
appropriate. 

Anesthesia." — The  alypin  or  cocain  lubricant  has  been  described 
above.  Fortified  by  an  injection  of  morphin  this  will  control  almost 
any  patient.  I  have  employed  spinal  anesthesia  a  number  of  times 
for  cystoscopy ;  but  not  in  the  past  year.  For  a  patient  who  expects  to 
be  out  of  bed  the  day  after  his  examination  is  peculiarly  likely  to  de- 
velop severe  headache  from  the  spinal  puncture. 

General  anesthesia  for  cystoscopy  of  a  tubercular  bladder  is  likely  to 
produce  a  more  severe  reaction  than  the  same  anesthesia  when  repeated 
for  a  subsequent  nephrectomy. 

Position. — Since  the  bladder  may  not  empty  itself  spontaneously 
through  the  sheath  of  the  cystoscope  if  the  patient  lies  flat,  the  head 
of  the  table  should  be  raised.  The  buttocks  are  brought  to  the  end  of 
the  table,  the  feet  or  knees  supported  on  rests  (the  ordinary  lithotomy 
stirrup  is  most  uncomfortable). 

The  nervous  woman  much  prefers  being  cystoscoped  in  the  Sims' 

'  But  it  does  not  interfere  with  guinea-pig  inoculations  for  tlie  diagnosis  of 
tuberculosis. 


THE  CYSTOSCOPY  53 

position.     If  the  bladder  is  fairly  normal  this  does  not  entail  very 
grave  inconvenience  to  the  operator. 
Antisepsis. — See  above. 


THE  CYSTOSCOPY 

Testing  the  Instrument. — When  all  is  ready,  the  operator  glances 
through  the  telescope  to  be  sure  the  lenses  are  not  fogged,  then  attaches 
the  sheath  of  the  cystoscope  to  the  source  of  electricity  to  test  the  lamp. 
The  rheostat  is  set  at  the  correct  point,  the  wires  again  disconnected. 

Introduction  of  the  Instrument. — The  cystoscopic  sheath  with  its 
obturator  in  place  is  lubricated  and  introduced. 

The  female  urethra  presents  no  obstruction  other  than  a  little  tight- 
ness sometimes  encountered. 

The  cystoscope  is  introduced  into  the  male  urethra  like  a  sound. 
Its  entry  into  the  posterior  urethra  is  facilitated  by  firm  downward 
pressure  over  the  pubes  to  relax  the  suspensory  ligament.  It  may  slip 
quite  readily  over  the  bladder  neck  or  it  may  have  to  be  still  further  de- 
pressed, aided  by  the  pubic  counterpressure  until  the  long  axis  of  the 
shaft  swings  beyond  that  of  the  patient's  body.  The  tip  may  even  have 
to  be  lifted  by  a  finger  introduced  into  the  rectum.  But  one  must 
always  remember  that,  as  in  the  case  of  the  sound,  entrance  into  the 
bladder  is  effected  by  swinging  the  shaft  into  correct  position,  not  hy 
pushing. 

Any  doubt  as  to  whether  the  instrument  has  actually  entered  the 
bladder  is  settled  by  removing  the  obturator,  and  injecting  a  little 
water.  This  returns  freely  if  the  cystoscope  is  properly  placed  (with 
its  aperture  turned  toward  the  vault  of  the  bladder). 

Irrigation. — Enough  water  is  then  injected  to  clear  the  bladder  of 
blood,  pus  and  lubricant.  This  is  most  quickly  accomplished  by  in- 
jecting about  50  c.c.  at  a  time.  When  using  a  modern  irrigating  instru- 
ment one  need  not  irrigate  the  bladder  beforehand,  or  take  any  special 
precaution  to  have  the  fluid  absolutely  clean  before  introducing  the 
telescope.  For  repeated  in-and-out  irrigation  during  the  operation  is 
the  best  method  of  cleaning  the  field  of  much  pus  or  blood. 

Examination. — The  telescope  is  then  introduced,  a  stop-cock  opened 
to  admit  the  irrigating  fluid,  and  the  examination  begun  as  the  bladder 
is  filling  with  water.  The  patient's  complaint,  if  the  bladder  is  much 
inflamed,  or  the  obliteration  of  folds,  if  it  is  not,  is  the  signal  for 
shutting  oft'  the  inflow  of  water. 

The  order  in  which  the  various  parts  of  the  bladder  are  examined 
will  depend  upon  the  habit  of  the  operator,  and  will  vary  somewliat 
with  the  emergency  of  the  case.     But  it  is  well  to  follow  a  definite  sys- 


54  CYSTOSCOPY 

tern  lest  one  overlook  some  unsuspected  lesion.  The  common  practice 
of  plunging  the  cystoscope  into  the  bladder  and  two  catheters  into 
the  ureters,  and  then  retreating  without  so  much  as  a  glance  about  the 
rest  of  the  organ  cannot  be  too  strongly  condemned. 

AVe  employ  the  following  order  in  examining  the  bladder:  the 
bladder  neck,  the  trigone,  the  ureter  orifices,  the  fundus,  especially  that 
part  adjacent  to  the  ureters,  and  finally  the  vault.  With  certain  cysto- 
scopes  one  may  also  examine  the  posterior  urethra  as  one  withdraws 
the  instrument  from  the  bladder. 

Ureter  Catheterism.^If  indicated,  the  ureters  are  then  catheterized 
(p.  67),  or— 

Intravesical  Operations — Any  operative  work  performed. 

Close  of  the  Cystoscopy — At  the  close  of  the  cystoscopy  the  bladder 
is  emptied,  through  the  sheath,  after  withdrawal  of  the  telescope. 
Then  there  should  be  injected  about  50  c.c.  of  1 :  5,000  silver  nitrate 
solution,  to  be  urinated  out  by  the  patient  (if  he  can  empty  his  bladder) 
or  withdrawn  through  the  cystoscopic  sheath  (if  he  cannot). 

Treatment  after  Cystoscopy .^To  most  patients  a  cystoscopy  means 
no  more  than  a  considerable  discomfort  for  a  few  minutes,  followed  by 
a  soreness  at  the  neck  of  the  bladder  lasting  a  day  or  so.  But  the  opera- 
tion may  be  followed  by  a  chill,  cystitis,  pyelonephritis  or  renal  colic. 
The  infectious  complications  only  occur  in  cases  already  infected  and 
draining  badly.  Hence  they  may  be  foreseen  and  properly  guarded 
against  by  antisepsis,  gentleness,  and  keeping  the  patient  quiet. 

Renal  colic  following  ureter  catheterism  may  not  be  foreseen.  Its 
usual  cause  is  probably  ureteral  occlusion  by -blood  clot.  Yet  it  seems 
much  rarer  in  those  who  are  able  to  rest  after  the  operation  than  in 
those  who  have  to  go  about.  Consequently  it  is  wise  to  set  the  cystos- 
copy for  a  time  when  the  patient  shall  have  nothing  to  do  for  the  rest 
of  the  day.  Inflammatory  complications  following  the  operation  are 
to  be  treated  in  accordance  with  the  usual  rules. 


APPEABANCE  OF  THE  NORMAL  BLADDER 

The  Normal  Bladder  Neck. — As  soon  as  the  bladder  begins  to  fill 
with  fluid  one  may  examine  the  bladder  neck.  With  the  prism  directed 
upward,  the  cystoscope  is  gently  withdrawn  until  there  suddenly  appears 
in  the  field,  close  to  the  instrument,  a  dark  red  body.  This  is  the 
bladder  neck.  If  normal  it  has  a  crescentic  fold  with  the  concavity 
away  from  the  cystoscope.  This  fold  may  be  smooth  and  regular, 
and  upon  it  one  may  see  the  red  outlines  of  the  vessels  within  the 
mucosa,  or  it  may  be  lumpy  and  edematous  looking,  showing  no  visible 
vessels.  Though  such  a  picture  suggests  inflammation  it  may  well 
be  entirely  within  the  normal,  and  one  should  not  infer  that  the  bladder 


THE  CYSTOSCOPY  55 

neck  is  inflamed  unless  the  cystoscope  shows  evidence  of  inflamma- 
tion elsewhere. 

Keeping-  this  crescentic  fold  in  the  field  the  cystoscope  is  now  re- 
volved in  the  direction  of  the  hands  of  a  watch.  The  normal  bladder 
neck  retains  its  concave,  sharply  outlined  appearance  until  the  cysto- 
scope has  made  about  one-third  of  a  revolution.  At  "four  o'clock," 
however,  the  sharply  outlined  ring  flows  insensibly  into  the  trigone. 
The  ring  is  lost  in  this  red  surface  until  the  cystoscope  has  completed 
another  third  of  its  circle.  Then  at  "eight  o'clock"  it  is  picked  up 
again  and  carried  around  to  the  starting  point.  At  the  junction  of 
bladder  neck  and  trigone  one  can  follow  the  lateral  edge  of  the  trigone 
as  a  rather  well-defined  ridge,  by  pushing  the  instrument  inward. 

The  Normal  Trigone — Having  completed  the  inspection  of  the 
bladder  neck,  the  cystoscope  is  once  again  revolved  a  half  turn  to  "six 
o'clock."  With  the  prism  looking  downward  it  is  now  pushed  into 
the  bladder  about  one  centimeter  and  as  it  goes  one  observes  the  sur- 
face of  the  trigone;  a  surface  covered  with  a  sheaf  of  vessels  spread 
fanwise  from  the  bladder  neck  toward  the  posterior  edge  of  the  trigone 
(interureteric  bar).  That  these  vessels  are  not  plainly  visible  may 
simply  mean  that  the  prism  is  too  close  to  the  trigone.  Depress  the 
instrument  a  trifle  and  they  spring  into  view.  After  the  cystoscope 
has  thus  been  pushed  in  about  one  centimeter  from  the  bladder  neck 
the  edge  of  the  trigone,  the  interureteric  bar,  springs  into  view.  Up 
to  this  point  the  mucosa  of  the  trigone  has  been  smooth,  a  rather  dark 
red,  and  streaked  with  its  radiating  vessels.  Beyond  this  transverse 
bar  is  seen  the  fundus,  rather  wrinkled  than  smooth,  distinctly  paler 
than  the  trigone,  and  etched  w^ith  smaller  vessels  running  hither  and 
thither  quite  irregularly. 

The  prominence  of  the  interureteric  bar  varies  gTcatly  in  different 
individuals,  and  with  different  degrees  of  bladder  distention.  If  the 
bladder  is  only  partly  filled,  and  the  patient  a  man,  the  bar  usually 
stands  out  quite  distinctly  with  a  definite  pocket  immediately  behind. 
But  if  the  bladder  is  distended,  and  the  patient  a  woman,  especially 
a  multiparous  woman,  the  trigonal  markings  may  be  quite  obliterated ; 
so  that  one  cannot  tell  precisely  where  the  trigone  ends  and  the  fundus 
begins.  Here  again  the  novice  is  likely  to  make  the  mistake  of  keeping 
the  cystoscopic  prism  too  close  to  the  bladder  wall.  If  he  becomes 
confused  let  his  first  thought  ])e  to  depress  the  ocular  end  of  the  prism 
in  order  to  get  a  more  distinct  view  of  the  interureteric  fold.  Indeed,  if 
the  lens  is  kept  a  little  way  from  the  trigone  the  whole  of  it  will  be 
inspected  by  the -motion  of  pushing  the  cystoscope  in  until  the  inter- 
ureteric  fold  comes  into  view,  and  then  turning  it  to  find  the  ureters. 

The  Normal  Ureter  Mouth. — After  the  interureteric  bar  has  been 
identified  the  ureter  mouth  is  brought  into  view  by  simply  rotating  the 


56  CYSTOSCOPY 

instrument  to  right  or  left  until  the  angle  of  the  trigone  is  seen  (Fig. 
26).  As  the  cystoseope  turns  the  eye  follows  the  bar  until  a  marked 
angle  or  rather  peninsula  of  smooth  trigonal  surface  is  seen.  This  is 
marked  by  a  few  remaining  radiating  trigonal  vessels,  is  more  or  less 
elevated  from  the  surrounding  fundus,  and  extends  laterally  and 
upward  to  be  lost  in  the  lateral  bladder  wall. 

As  soon  as  this  angle  of  the  trigone  is  brought  into  view  by  rotation 
of  the  cystoseope,  the  rotary  motion  is  exchanged  for  an  angular  de- 
pression, whereby  the  ocular  end  of  the  instrument  is  turned  away 
from,  and  the  prism  is  brought  toward,  the  angle  of  the  trigone.  Xear 
the  base  of  the  little  peninsula,  and  usually  fairly  in  its  middle  line, 
the  ureter  orifice  will  be  seen. 

The  description  of  the  ureter  orifice  is  an  entirely  hopeless  task, 
for  no  two  normal  orifices  look  exactly  alike.  The  color  depends 
largely  upon  the  illumination  and  distention  of  the  bladder.  One  may 
lay  down  the  rule  that  neither  ureter  orifice  nor  bladder  neck  should 
be  considered  inflamed  unless  there  is  evidence  of  inflammation  on  the 
adjacent  bladder  wall. 

In  shape  the  nonual  ureter  orifice  may  appear  a  wee  round  hole, 
a  slit,  or  a  ^'U"  fold  of  mucosa.  Contraction  of  the  ureter  shows  itself 
by  a  slight  motion  in  the  mucosa  followed  by  a  sudden  opening  of  the 
little  hole  or  slit  from  which  comes  a  swirl  of  urine.  Xo  very  profound 
conclusions  can  be  drawn  from  watching  the  contractions  of  the  ureter. 
It  may  be  important  to  note  that  a  bloody  or  purulent  flood  issues  from 
it,  and  one  may  note  that  it  does  contract.  But  that  it  does  not  contract 
proves  nothing.     This  may  be  due  to  reflex  inhibition  of  peristalsis. 

Another  Way  of  Finding  the  Ureter. — Inasmuch  as  the  ureter 
mouth  lies  at  the  junction  of  the  base  and  lateral  edge  of  the  trigone, 
it  may  be  found  by  following  either  of  these  lines.  The  method  just 
described  is  the  most  generally  satisfactory ;  but  in  some  instances  oblit- 
eration of  the  trigonal  markings  may  make  the  lateral  edge  of  the  tri- 
gone a  better  guide.  This  extends  from  the  bladder  neck  (at  about 
"four"  or  "eight  o'clock")  almost  directly  inward  to  the  angle  of  the 
trigone,  and  usually  can  be  quite  readily  followed,  if  the  prism  of  the 
cystoseope  is  depressed  fairly  close  to  the  trigone,  and  rotated  toward  the 
side  so  as  to  throw  the  lateral  edge  into  sharp  relief  against  the  bladder 
wall  behind  it. 

The  Normal  Fundus. — The  fundus  is  that  part  of  the  bladder  lying 
immediately  about  and  beyond  the  trigone.  Its  surface  is  somewhat 
irregular,  even  when  the  bladder  is  full,  and  when  the  organ  is  not 
fully  distended  the  fundus  may  be  thrown  wrinkled  in  folds  of  con- 
siderable depth.  For  a  proper  examination  of  this  surface  it  should 
be  fairly  well  upon  the  stretch.  Then  it  appears  as  a  relatively  pale 
mucous  membrane,  covered  with  interlacing  small  red  blood  vessels. 


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58  CYSTOSCOPY 

The  region  about  the  angles  of  the  trigone  should  be  most  carefully 
examined  as  this  is  the  point  of  origin  of  most  primary  papillary 
tumors  and  saccules ;  while  here  also  may  be  seen  the  most  intense  evi- 
dence of  tubercular  and  other  inflammations. 

To  examine  the  fundus  fully  the  ocular  end  of  the  cystoscope  should 
be  depressed,  and  the  instrument  pushed  until  it  will  go  no  further,  or 
until  the  light  becomes  obscured  by  a  fold  of  bladder  wall.  The  instru- 
ment is  then  withdrawn  again  toward  the  trigone  and,  both  going  and 
coming,  it  is  rotated  gently  from  side  to  side,  so  that  the  eye  sweeps 
across  the  whole  base  of  the  bladder. 

The  Normal  Vault. — The  cystoscope  is  then  turned  over  until  its 
prism  points  directly  upward.  In  the  rather  dim  distance  one  sees 
the  pearly  bubble  of  air  that  floats  at  the  top  of  the  water  in  the 
bladder,  and  forms  the  center  from  which  our  observations  radiate. 
From  this  center  one  withdraws  the  instrument,  moving  it  a  little  from 
side  to  side,  and  inspecting  the  bladder  w^all  until  the  bladder  neck 
comes  into  view ;  then  back  to  the  bubble,  and  a  lateral  wall  is  inspected, 
as  the  instrument  is  slowly  swept  downward  until  the  trigone  comes 
into  view.  The  opposite  wall  is  then  covered  in  the  same  way,  and 
finally  the  ocular  end  of  the  instrument  is  elevated  and  the  instrument 
pushed  inward  until  one  has  seen  all  that  remains  of  the  bladder  wall 
beyond  the  bubble.  The  appearance  of  the  wall  of  the  normal  bladder 
is  the  same  at  the  vault  as  at  the  fundus. 


CHAPTER    VI 
CYSTOSCOPY  OF  THE  DISEASED  BLADDER 

Indications  for  Cystoscopy — Cystoscopy  is  required  for  the  precise 
diagnosis  of  every  disease  of  the  bladder  and  ureters,  and  every  surgical 
disease  of  the  kidneys.  To  enumerate  these  would  be  to  waste  space. 
Even  the  expert  may  profitably  hold  strictly  to  the  letter  of  this  rule. 
The  very  case  in  which  it  seems  most  reasonable  to  omit  cystoscopy 
may  conceal  some  important  and  unsuspected  element  that  could  have 
been  revealed  only  by  this  method  of  examination. 

Centra-indications  of  Cystoscopy — The  most  absolute  contra-indi- 
cation  to  cystoscopy  is  ignorance  or  incompetence  on  the  part  of  the 
operator.  Interpretations  of  pathological  conditions  must  be  founded 
upon  a  long  and  careful  study  of  normal  conditions.  In  the  patient, 
himself,  urethral  obstruction  by  stricture,  prostate  or  calculus  may  pro- 
hibit cystoscopy.  Gonorrhea  is  a  contra-indication  unless  the  need  of 
information  is  imperative  and  the  importance  of  the  information  to  be 
gained  outweighs  the  danger  from  urethral  trauma.  Other  contra- 
indications, such  as  the  irritable  bladder  itself  or  the  patient's  debility, 
may  usually  be  met  by  careful  preparation  and  intelligent  selection  of 
anesthesia. 

THE  INFLAMED  BLADDER 

That  the  bladder  is  not  inflamed  is  judged  from  the  appearance  in 
its  mucous  membrane  of  fine  branching  blood  vessels.  AVhen  these 
blood  vessels  cannot  be  seen  (through  a  clear  medium)  the  bladder  is 
inflamed.  The  neophyte  will  mistake  variations  in  color  of  the  mucous 
membrane  for  inflammation,  though  such  variations  may  be  due  to  dif- 
ferences in  bladder  distention  and  degree  of  illumination.  This  tend- 
ency to  see  inflammation  where  it  does  not  exist  he  will  evince  espe- 
cially in  relation  to  the  urethral  and  ureteral  orifices,  ]\[ild,  general 
cystitis  shows  itself  only  by  the  disappearance  of  branching  vessels  that 
should  be  seen  in  fundus  and  vault.  The  trigone  is  almost  invariably 
the  seat  of  the  most  marked  inflammation.  Here  it  is  difficult  to  dis- 
tinguish slight  inflammation  since  this  may  not  absolutely  obscure  the 
vessels.  A  more  intense  inflammation  sliows  itself  characteristically 
by  throwing  the  naturally  smooth  surface  of  the  mucosa   into  little 

59 


60  CYSTOSCOPY  OF  THE  DISEASED  BLADDER 

irregularities  resembling  a  granulating  surface.  But  the  suggestion  of 
inflammation  upon  the  trigone  should  always  be  certified  by  the  absence 
of  vessels  in  the  adjoining  portions  of  the  fundus.  Observation  of  this 
will  prevent  many  mistaken  diagnoses  of  inflammation  about  the  blad- 
der neck,  or  about  the  ureter  mouth.  The  more  chronic  the  inflamma- 
tion of  the  bladder  the  more  likely  it  is  to  be  localized. 

The  appearance  of  irregularly  distributed  areas  of  redness  and 
obliteration  of  the  bladder  vessels  is  often  spoken  of  as  characteristic 
of  tuberculosis.  Yet  this  condition  is  seen  in  many  non-tuberculous 
conditions;  especially  in  cases  of  bladder  sacculation,  ureteral  stone 
and  non-tuberculous  pyonephrosis. 

Ulcers  upon  the  bladder  wall  occurring  in  the  course  of  an  acute 
cystitis  appear  as  little  white  spots  quite  comparable  to  aphthous  spots 
of  the  mouth.  The  ulceration  of  the  chronic  cystitis  is  seen  as  an  area 
set  in  the  midst  of  red  mucosa  that  looks  like  granulation  tissue.  The 
surface  of  the  ulcer  itself  is  usually  covered  with  a  sloughy  mucous 
membrane  to  which  blood  clots  or  phosphatic  crystals  may  be  adherent. 
Sometimes  the  ulcerated  surface  is  distinctly  papillary,  and  suggestive 
of  neoplasm.  Leukoplakia  I  have  seen  but  twice.  It  showed  a  white 
pearly  surface  in  the  midst  of  an  intensely  inflamed  patch.  The  changes 
in  the  ureter  mouth  seen  in  cystitis  are  often  suggestive  of  the  origin 
of  the  inflammation.     They  are  described  below. 


TUBERCULOUS  CYSTITIS 

The  changes  described  above  (with  the  exception  of  leukoplakia) 
may,  any  or  all  of  them,  be  seen  in  the  tuberculous  bladder.  The  more 
intense,  ulcerative  and  localized  the  inflammation,  and  the  more  it  cen- 
ters about  one  or  the  other  of  the  ureter  orifices,  the  more  likely  is  it 
to  be  tuberculous.  It  is  perilous  to  describe  any  type  of  cystitis  as 
peculiar  to  tuberculosis.  Even  the  little  tubercles  in  the  mucosa  may 
be  simulated  in  cystitis  cystica. 


THE  INFLAMED  URETER  MOUTH 

The  acutely  inflamed  ureter  mouth  shows  a  distinct  edematous 
swelling  of  its  lips.  The  redness  spreads  over  and  obliterates  the 
vessels  on  the  adjacent  portion  of  the  fundus.  As  a  result  of  the  pouting 
of  the  ureteral  orifice  it  looks  as  though  the  opening  were  enlarged, 
though  doubtless  the  swelling  actually  diminishes  the  lumen  of  the 
canal. 

Chronic  inflammation  of  the  ureter  mouth  includes  five  changes. 


THE  INFLAMED  URETER  MOUTH  61 

viz. :  surface  inflammatory  changes,  change  in  shape,  change  in  function 
retraction,  and  change  in  the  ejected  stream  {See  PI.  I). 

Surface  Inflammatory  Changes. — These  are  simihir  to  the  changes 
of  chronic  cystitis  already  described.  The  ureter  orifice  may  be  lost 
in  the  inflamed  mucosa  or  it  may  appear  as  an  intensely  inflamed  or 
ulcerated  region  in  the  midst  of  which  the  ureter  mouth  is  very  hard  to 
find  unless  dilated. 

Change  in  Shape. — Inflammatory  infiltration  and  cicatricial  con- 
traction about  the  chronically  inflamed  ureter  mouth  may  cause  various 
changes  in  its  shape.  As  a  rule  the  orifice  is  dilated  while  the  inflamma- 
tion is  still  active.  This  dilatation  may  make  it  appear  as  a  long  slit, 
or  as  a  relatively  open  round  hole.  The  earlier  cystoscopists  used  to 
describe  a  "golf-hole"  ureter,  a  rigid,  round,  wide  orifice.  Such  an  ori- 
fice is  typical  of  prolonged  chronic  ureteritis.  But  it  is  not  often  seen, 
nor  is  its  absence  any  evidence  of  the  fact  that  the  ureter  is  not  chron- 
ically inflamed.  The  "golf-hole"  is  changed  to  a  "tunnel  entrance"  by 
retraction  of  the  ureter  mouth,  as  described  below. 

Change  in  Function. — Just  as  the  ureter  may  be  chronically  and 
severely  inflamed  without  any  notable  change  in  the  shape  of  its  oriflce, 
so  its  function  is  unimpaired  by  chronic  inflammation  unless  that  in- 
flammation has  invaded  the  muscular  coat  and  impaired  its  peristaltic 
action.  If  this  has  occurred  the  ureter  remains  still  and  open,  while 
the  purulent  or  bloody  urine  dribbles  from  it  in  a  more  or  less  constant 
stream. 

Retraction. — Retraction,  like  interference  with  function,  means  in- 
flltration  of  all  the  coats  of  the  ureter  of  sufficient  intensity  and  dura- 
tion to  impair  the  elasticity  of  the  duct  and  so  to  pull  the  ureter  mouth 
upward  and  outward.  Such  retraction  is  often  associated  with  con- 
siderable inflammation  and  ulceration  about  the  ureter  mouth.  But  if 
this  has  in  large  measure  subsided,  the  ureter  mouth  may  be  left  open, 
"golf-hole,"  and  this  "golf-holed"  oriflce  retracted  toward  the  side  of 
the  bladder  appears  like  the  entrance  to  a  tunnel,  with  the  smooth,  pale, 
scarred,  tense  trigone  appearing  as  the  floor  of  the  tunnel. 

Change  in  the  Ejected  Stream. — Inasmuch  as  the  inflammation 
about  the  ureter  mouth  usually,  though  not  inevitably,  implies  infection 
of  the  kidney  pelvis,  one  may  look  for  pus  in  the  urine  ejected.  But 
even  though  the  kidney  be  gravely  diseased,  the  amount  of  pus  in  the 
ejected  ureteral  stream  may  be  so  little  as  to  be  distingiiishable  only 
under  the  best  of  circumstances  as  to  light,  freedom  from  pain  and 
freedom  from  pus  within  the  bladder,  which  can  often  not  be  com- 
manded. Therefore,  while  meatoscopy,  as  it  is  called  (i.  e.,  inspection 
of  the  ureter  mouth)  may  reveal  pus  issuing  from  the  ureter,  this  in- 
formation is  obtained  more  accurately  by  ureter  eathetprism.  Any  con- 
siderable delay  for  inspection  of  the  stream  as  it  issues  from  the  ureter 


62  CYSTOSCOPY  OF  THE  DISEASED  BLADDER 

is  worth  while  only  when  some  previous  effort  has  shown  that  it  is 
impossible  to  introduce  the  ureter  catheter. 


PROSTATIC  LOBES 

The  projecting  lobes  of  an  enlarged  prostate  show  much  more  plainly 
within  the  bladder  than  they  do  by  rectal  touch.  If  there  is  enlarge- 
ment of  the  middle  lobe  this  is  distinctly  seen  as  a  tumor  arising  from 
the  floor  of  the  urethra ;  so  that  when  the  cystoscope  is  swept  around 
the  ring  of  the  bladder  neck,  at  about  the  place  where  this  should  dis- 
appear into  the  trigone,  one  sees  a  fold  and  then  a  marked  projection, 
a  convex  instead  of  a  concave  object.  This  convexity  crosses  the  middle 
line  to  where  the  ring  of  bladder  neck  is  met  beyond. 

If  there  is  a  single  lateral  lobe  that  side  of  the  bladder  neck  is  in 
the  same  way  transformed  from  a  concavity  to  a  convexity  with  a 
sharp  angle,  or  fold  of  the  mucous  membrane  at  each  extremity.  Two 
lateral  lobes  project  on  each  side  with  a  fissure  between  them  above, 
and  below.  Two  lateral  lobes  and  a  middle  lobe  show  a  set  of  three 
convexities  with  three  deep  folds  between  them  (PI.  II).  The  size 
of  the  lobe  may  be  measured  by  the  distance  the  cystoscope  must  be 
introduced  to  keep  the  edge  of  the  projecting  lobe  within  the  field. 
Such  measurements  are  not  wholly  accurate. 

BAR  OR  CONTRACTURE 

A  bar  or  contracture  may  be  utterly  invisible.  Sometimes,  however, 
one  sees  a  raised  bladder  neck  with  the  trigone  singularly  depressed 
beyond  it,  somewhat  similar  to  the  normal  picture  of  the  interureteric 
fold. 

CARCINOMA  OF  THE  PROSTATE 

A  small  carcinoma  may,  like  a  bar,  produce  no  change  in  the  cysto- 
scopic  picture,  while  a  large  carcinoma  may  so  distort  the  deep  urethra 
as  to  prevent  the  introduction  of  a  cystoscope.  Sometimes  the  cysto- 
scope reveals  irregular  changes  in  the  shape  of  the  bladder  neck — ^usu- 
ally a  series  of  irregular  small  nodules.  These  may  be  mistaken  for 
inflammation  or  for  an  irregTilar  type  of  prostatism  unless  they  extend 
into  the  trigone  or  vault.  Actual  infiltration  of  the  mucous  membrane, 
in  the  form  of  carcinomatous  ulceration  or  papillary  growths,  is  not  so 
often  seen  (PL  I,  Fig.  6). 

Since  the  carcinoma  is  usually  primary  in  the  posterior  lobe,  one 
usually  learns  more  by  rectal  touch  than  by  cystoscopy. 


PLATE    II 


Cystoscopic  Interpretation  of  the  Appearance  of  the  Bladder  Neck  in  Prostatism. 

Fig.  1. — General  prostatic  hypertrophy,  middle  and  lateral  lobes  forming  one  mass — as  seen 

by  the  cystoscope. 
Fig.  2. — Schematic  interpretation  of  Fig.  1. 
Fig.  3. — The  actual  condition 


TUMOR  OF  THE  BLADDER  63 


TUMOR  OF  THE  BLADDER 

Papillary  Tumors. — Cystoscopic  inspection  does  not  disclose  the 
malignancy  of  a  papillary  growth  in  the  bladder.  Inflammatory  ulcera- 
tions whether  encrusted  or  not  may  well  he  papillary.  But  such  papillae 
are  relatively  short  and  are  distributed  over  a  relatively  large  bladder 
surface.  They  are  obviously  not  neoplastic.  The  papillary  neoplasm, 
if  small,  is  seen  as  a  tuft  of  villi  growing  from  a  tenuous  pedicle.  The 
large  papillary  neoplasm  is  likely  to  have  a  cauliflower-like  appearance, 
the  villi  being  packed  so  close  together  as  to  appear  fused  in  bunches. 
Such  a  large  neoplasm  may  more  than  fill  the  cystoscopic  field,  and 
bleed  so  freely  as  to  obscure  the  diagnosis.  The  villi  also  choke  the 
sheath  of  the  cystoscope  and  interfere  with  irrigation.  Such  tumors 
are  often  multiple. 

The  Ulcerated  Papillary  Tumor — Spontaneous  ulceration  of  a  pap- 
illary tumor  usually  means  that  it  is  malignant.  The  ulceration  covers 
more  or  less  of  the  surface  of  the  growth  with  a  white  slough,  to  which 
phosphatic  grit  is  likely  to  be  found  adherent. 

The  Non-papillary  IFlcerated  Neoplasm — Carcinomatous  ulceration 
of  the  bladder  wall  cannot  be  readily  distinguished  by  inspection  from 
inflammatory  ulceration.  Inflammatory  ulcers  usually  appear  about 
the  trigone  and  bladder  neck  while  malignant  ulcers  affect  the  vault 
and  fundus. 

Secondary  Carcinoma  of  the  Bladder — Carcinoma  invading  the 
bladder  from  the  prostate,  the  uterus,  or  other  adjacent  organs  is  dis- 
covered by  other  means  than  cystoscopy  but  the  cystoscope  measures 
the  involvement  of  the  bladder  wall.  The  earliest  change  (excepting 
growths  coming  from  the  prostate)  is  fixation  of  the  bladder  wall  at  the 
point  of  invasion.  The  fixation  may  sometimes,  though  not  always, 
be  recognized  when  the  bladder  is  fully  distended  by  wrinkling  or 
dimpling  of  the  surface  drawn  to  one  side.  This  fixation  in  cases  of 
tumors  extending  from  the  uterus  is  likely  to  show  itself  in  the  fundus 
just  back  of  the  ureteral  orifices.  As  the  carcinoma  extends  further 
into  the  bladder  wall  the  surface  of  the  mucous  membrane  is  thrown 
into  red,  edematous  folds.  The  picture  shows  a  circumscribed  region 
not  unlike  chronic  cystitis  in  appearance.  Ulceration  does  not  occur 
until  infiltration  has  existed  for  a  considerable  time.  Bullous  edema, 
or  vesicles,  may  appear  early  (PI.  I,  Fig.  5). 

Non-infiltrating  Neoplasms. — Under  this  term  we  inchide  the  non- 
malignant  myofibroma  of  the  bladder  wall  itself,  and  such  tumors  of 
the  adjacent  tissue  (whether  malignant  or  not)  as  depress  the  bladder 
wall  without  invading  it.  Such  tumors  are  recognized,  after  full  dis- 
tention of  the  bladder,  by  the  fact  that  they  project  more  or  less  mark- 


64  CYSTOSCOPY  OF  THE  DISEASED  BLADDER 

edlj  into  the  bladder  cavity,  and  difference  in  distention  does  not  ma- 
terially alter  the  position  of  the  point  of  projection.  The  mucosa  over 
snch  projections  may  or  may  not  be  inflamed  (PL  I,  Fig.  4). 

Cystitis  Cystica — This  condition  is  recognized  as  a  scattered  or 
grouped  collection  of  pearly  or  pink  vesicles  distributed  over  a  more  or 
less  reddened  surface  of  the  bladder. 


CHANGES  IN  THE  SHAPE  OF  THE  BLADDER 

Apart  from  the  normal  variations  and  inflammatory  changes  in  the 
shape  of  the  ureteral  orifice,  and  the  changes  in  the  shape  of  the  urethral 
orifice  due  to  prostatism  or  neoplasm,  the  following  changes  are  note- 
worthy : 

1.  Cystocele. 

2.  Ureterovesical  cysts. 

3.  Trabeculation  and  sacculation. 

Cystocele — The  importance  of  cystocele  is  measured  chiefly  by  the 
vaginal  protrusion,  the  amount  of  residual  urine  and  the  secondary 
cystitis.  A  cystoscopic  measure  of  its  extent  is  the  angle  at  which  the 
cystoscope  must  be  tilted  in  order  to  examine  the  ureter  orifice;  for 
in  proportion  as  the  anterior  vaginal  wall  gives  way,  the  trigone  drops 
from  the  long  axis  of  the  patient's  body  to  the  transverse  axis.  So 
that  to  approach  the  ureter  orifice  of  the  well-filled  bladder  in  a  case  of 
cystocele,  the  ocular  end  of  the  cystoscope  must  be  carried  well  for- 
ward under  the  pubes.  Even  when  this  is  done  the  trigonal  markings 
are  so  much  obliterated  in  these  cases  that  identification  of  the  ureter 
mouth  is  often  extremely  difficult  (PL  I,  Fig.  1). 

Ureterovesical  Cyst — Small  dilatations  of  the  submucous  portion 
of  the  lower  end  of  the  ureter  are  seen  as  little  pouches  that  balloon 
up  with  each  wave  of  ureter  peristalsis.  If  large  they  are  seen  as  more 
or  less  fully  distended  cysts.  If  enormous  they  may  so  fill  the  bladder 
and  distort  its  landmarks  as  to  be  very  difficult  of  diagnosis  without 
collargol  injection  (PL  I,  Fig.  14). 

Trabeculation — The  beginner  mistakes  the  folds  in  the  fundus  of 
the  normal  bladder  for  trabeculation ;  practice  in  cystoscopy  will  rem- 
edy this  error.  Slight  trabeculation  can  only  be  recognized  when  the 
bladder  is  completely  filled;  it  then  appears  as  a  crisscrossing  of  little 
short  elevated  ridges  in  the  mucosa  (PL  I,  Fig.  3).  It  is  usually  most 
marked  in  the  fundus.  Marked  trabeculation  is  unmistakable,  and  is 
often  associated  with  sacculation. 

Sacculation — The  orifice  of  a  saccule  is  simply  a  hole  in  the  bladder 
wall.  The  mucous  membrane  about  this  may  or  may  not  appear  in- 
flamed.    It  may  be  possible  to  turn  the  cystoscope  so  as  to  be  able  to 


DIFFICULTIES  IN  CYSTOSCOPY  65 

see  the  bottom  of  the  saccule.  But  as  a  rule  its  size  can  only  be  meas- 
ured roughly  by  the  introduction  of  a  graduated  ureter  catheter,  and 
more  accurately  for  the  larger  saccules,  by  collargol  injection  and 
radiography.  An  enormous  saccule  may  so  distend  the  bladder  as  to 
confuse  the  cystoscopic  picture.  In  such  cases  collargol  injection  is  the 
only  resource  available. 

STONE 

Bladder  stones  so  often  contain  no  lime  salts  that  they  are  over- 
looked by  the  x-ray.  The  cystoscopist  readily  identifies  small  stones  as 
white,  yellowish  or  brown,  rounded,  movable  bodies.  They  are  usually 
seen  beside  or  above  the  cystoscope,  rather  than  below  it.  Large  stones 
will  be  struck  by  the  cystoscope  as  it  is  introduced  and  may  simply 
show  an  irregTilar  sloughy  looking  surface  which  is  not  alwa3"s  readily 
distinguished  from  that  of  a  sloughy  neoplasm.  The  hardness  and 
mobility  of  the  stone  generally  settles  the  diagnosis.  It  is  to  be  remem- 
bered that  neoplasms  may  be  incrusted  with  phosphates,  and  thus  give  a 
gritty  contact.  Stone  in  a  saccule  is  almost  always  phosphatic,  and 
therefore  discoverable  by  the  x-ray.  It  may  be  visible  within  the 
orifice  of  the  saccule. 


DIFFICULTIES  IN  CYSTOSCOPY 

The  dangers  of  cystoscopy  have  already  been  mentioned  on  page 
54.  The  difficulties  of  cystoscopy  are  derived  from  sources  of  urethral 
obstruction,  bladder  irritability,  the  presence  of  pus  or  blood,  and  the 
presence  of  lesions  so  extensive  as  to  disfigure  the  cystoscopic  picture. 

Urethral  Obstmctions — These  are  to  be  dealt  with  as  for  a  passage 
of  a  sound  or  catheter :  the  meatus  cut ;  stricture  dilated  or  cut ;  the 
prostate  surmounted  by  forcible  depression  of  the  ocular  end  of  the 
cystoscope. 

The  Irritable  Bladder. — The  bladder  may  be  irritable  on  account 
of  nervousness  of  the  patient,  severe  inflammation  or  actual  contraction. 
Sympathetic  management  of  the  individual  and  thorough  anesthesia 
will  overcome  these  difficulties  in  large  measure.  The  modern  cysto- 
scope permits  a  fairly  complete  examination  with  no  more  than  50  c.c. 
of  fluid  in  the  bladder,  though  under  such  circumstances  one  may  fail 
to  catheterize  the  ureter. 

Pus  or  Blood. — The  presence  of  much  pus  or  blood  in  the  bladder 
reqaires  a  relatively  thorough  repeated  preliminary  irrigation  with 
sm-all  quantities  of  fluid.  If  the  bladder  is  sensitive  and  there  are  iio 
f'iots  in  it,  this  irrigation  should  be  carried  out  chiefly  by  means  of  the 


66  CYSTOSCOPY  OF  THE  DISEASED  BLADDER 

irrigation  vents;  these  admit  and  expel  the  fluid  much  more  gently 
and  slowly  than  when  the  opening  at  the  end  of  the  sheath  is  employed. 
If  blood  clots  are  present,  however,  a  few  injections  through  the  open 
sheath  with  the  syringe  (alternated  with  suction  if  the  injected  fluid 
does  not  return)  must  precede  the  more  gentle  manipulation.  Even  if 
the  bleeding  is  free  at  the  time  of  the  examination,  a  fairly  satisfactory 
exploration  may  still  be  made  by  patiently  going  over  the  bladder  wall 
bit  by  bit  while  alternating  the  inflow  and  outflow  through  the  vents, 
so  that  the  examination  is  made  practically  through  clear  fluid  that 
is  being  injected  into  the  bladder  before  contamination  with  blood  has 
time  to  occur.  This  method  of  examination  is  conducted  with  the 
bladder  almost  empty  all  the  time.  The  use  of  water  at  room  tem- 
perature probably  diminishes  the  bladder  and  ureteral  contraction  and 
this  somewhat  facilitates  the  examination. 

Pus  in  the  urine  itself  is  not  nearly  so  grave  an  interference  with 
cystoscopy  as  blood ;  for  the  pus  even  though  it  is  pure  and  flows  quite 
freely  from  the  ureter  never  contaminates  the  bladder  fluid  so  quickly 
as  free  bleeding  does.  Yet  the  bladder  that  contains  much  pus  is  likely 
to  be  a  gravely  inflamed  bladder  and  the  object  of  the  examination  is 
likely  to  be  catheterization  of  the  ureters  whose  mouths  are  lost  amid 
this  inflammation.  Under  such  circumstances  pyuria  may  prove  an 
insurmountable  difficulty. 


CHAPTEK    VII 

URETER  CATHETERISM 

The  day  has  at  last  dawned  when  substitutes  for  the  ureter  catheter 
are  not.  If  the  ureter  cannot  be  catheterized  we  realize  the  inaccuracy 
of  the  separators  of  Harris,  Cathelin  and  Luys,  and  the  danger  of 
depending  upon  meatoscopy.  Bilateral  exploratory  nephrotomy  gives 
the  only  prospect  of  a  diagnosis ;  and  the  information  afforded  by  this 
method  of  examination  is  far  less  accurate  than  that  afforded  by  the 
ureter  catheter. 

THE  CATHETER 

The  best  ureter  catheters  are  those  of  French  make.  For  many 
years  past  I  have  used  the  instruments  made  by  Eynard. 

Size — The  ideal  size  of  a  ureter  catheter  is  6  or  7  French  (12  to 
14  for  the  Eynard).  The  lumen  of  a  catheter  smaller  than  number  5, 
French,  is  too  small  to  convey  the  urinary  stream,  and  even  7,  French, 
is  too  large  to  enter  many  ureters  without  considerable  trauma.  There- 
fore I  usually  employ  a  6. 

The  Garceau  catheter  I  have  never  employed ;  though  it  might  be 
useful  to  dilate  a  stricture. 

Markii^gs — One  should  make  it  an  absolute  rule  never  to  use  two 
identical  catheters  for  an  examination.  There  must  always  be  a  dis- 
tinction between  that  which  is  to  enter  the  right  ureter  and  that  which 
is  to  enter  the  left.  This  distinction  should  be  announced  aloud  before 
the  examination,  and  should  be  verified  aloud  when  the  catheters  are 
in  place  and  the  cystoscope  withdrawn.  If  any  dispute  then  arises  as 
to  which  catheter  is  in  which  ureter  the  prevailing  opinion  may  be 
verified  in  the  female  by  vaginal  palpation  of  the  ureter  as  each  catheter 
is  withdrawn;  and  in  the  male  by  injection  of  enough  fluid  to  cause  a 
slight  renal  colic.  Inasmuch  as  one  is  interested  to  know  how  far  the 
catheter  enters  the  ureters  the  most  popular  type  of  instrument  is 
painted  black  on  each  alternate  centimeter  and  ringed  with  gold  at  in- 
tervals of  five  centimeters,  so  that  by  watching  the  catheter  enter  the 
ureter  one  may  estimate  precisely  how  far  it  has  gone.  It  is  my  custom 
to  use  for  each  examination  one  plain  catheter  and  one  marked  off  in 
centimeters,  as  the  equal  rings  and  markings  on  one  will  give  a  precise 

67 


68  URETER  CATHETERISM 

estimation  of  the  position  of  the  other  and  it  is  impossible  to  corfuse 
the  two. 

The  Tip.— Everv  ureter  catheter  should  have  at  least  two  eyes  on 
opposite  sides.  The  flnte-tipped  catheter  (Fig.  25)  is  the  Lest  instru- 
ment for  ordinary  use.  In  case  this  fails  to  enter  the  ureter  an  olivary- 
tipped  instrument  will  often  succeed. 


CATHETERISM  OF  THE  NORMAL  URETER 

We  assume  that  the  instruments  have  been  properly  sterilized;  the 
patient's  urethra  filled  with  the  anesthetic  antiseptic  lubricant;  the 
cystoscope  introduced  and  the  bladder  filled  and  examined. 

Finding  the  Ureter  Mouth. — The  two  methods  of  finding  the  ureter 
mouth,  i.e.,  by  the  interureteric  ridge  and  by  the  lateral  edge  of  the 
trigone,  have  already  been  described.  The  ureter  orifice  lies  usually 
in  the  middle  of  the  angle  of  the  trigone  at  the  base  of  its  little  penin- 
sula. It  is  a  slit,  a  round  hole  or  U-shaped.  It  is  flat  or  slightly  ele- 
vated ;  the  same  color  as  the  surrounding  mucosa  or  a  little  redder.  In 
order  to  see  it  clearly  the  beak  of  the  cystoscope  must  be  moved  to  one 
side  until  its  prism  is  almost  over  the  orifice  and  about  one  centi- 
meter from  it.  If  it  is  not  discovered  at  first  one  must  wait  patiently 
for  half  a  minute  or  so,  when  a  little  movement  will  be  seen  in  the 
angle  of  the  trigone  as  the  ureter  mouth  opens  to  eject  the  urinary 
stream.  If  the  cystoscope  is  rightly  placed  we  look  for  one  moment 
right  up  into  the  lumen  of  the  ureter.  If  after  a  half  minute  or  so  no 
sign  of  the  ureteral  contraction  is  seen,  the  ureter  catheter  should  be 
gently  pushed  out  for  about  two  centimeters  and  well  depressed  by 
turnino;  the  lever  to  a  ri^ht  angle.  Followins;  this  one  proceeds  to 
make  pressure  upon  different  points  of  the  angle  of  the  trigone,  using 
the  tip  of  the  catheter  to  probe  any  suspected  region,  or  laying  the  whole 
catheter  end  against  the  mucosa,  and  so  depressing  it,  in  the  hope  of 
bringing  the  adjacent  ureter  mouth  into  view.  The  beginner  will 
carry  out  these  manipulations  most  successfully  if  he  keeps  the  catheter 
fijsed,  and  moves  catheter  and  cystoscope  as  a  single  instrument.  If 
this  also  fails,  the  ureter  mouth  will  have  to  be  discovered  by  meatos- 
copy,  as  described  below. 

Introduction  of  the  Catheter. — Having  found  the  ureter  mouth,  the 
beak  of  the  cystoscope  is  moved  and  turned  toward  it  until  the  lens  is 
less  than  a  centimeter  away  from  it,  and  a  little  to  its  inner  side;  so 
that  we  are  looking  at  approximately  ''•!  o'clock'^  (for  the  right  ureter). 
The  corresponding  ureter  catheter  is  then  pushed  in  until  its  tip 
appears,  crosses  the  cystoscopic  field  and  passes  just  beyond  it.  Then 
the  lever  is  elevated  enough  to  bring  the  tip  back  into  the  center  of  the 


CATHETERISM  OF  THE  NORMAL  URETER  69 

field.  After  this,  levers  and  catheters  are  kept  rigid  while,  with  cysto- 
scope  and  catheter  acting  as  a  solid  body,  the  tip  of  the  instrument 
is  depressed  until  the  tip  of  the  catheter  touches  the  mucosa  just 
proximate  to  the  ureter  orifice.  Then,  again,  using  catheter  and  cysto- 
scope  as  a  single  solid  instrument,  it  is  pushed  inward  until  the  tip  of 
the  catheter  distinctly  engages  in  the  orifice  of  the  ureter.  TVith  the 
cystoscope  held  very  steady  the  catheter  is  now  gently  pushed  into  the 
ureter  orifice.  If  it  has  caught  in  the  mucosa  it  is  gently  withdrawn, 
turned  a  trifle  and  re-introduced.  It  is  quite  likely  to  be  caught  at 
about  1  cm.  within  the  ureter  orifice,  and  again  at  a  depth  of  5  cm.  it 
passes  the  tight  point  where  the  ureter  issues  from  the  bladder  wall. 

These  are  not  points  of  true  strictures  but  of  normal  irregularities 
in  the  ureter.  If  the  flute-tipped  catheter  will  not  pass  in,  it  must  be 
exchanged  for  an  olivary-tipped  instrument.  Beyond  5  cm.  the  cath- 
eter usually  goes  readily  enough,  though  in  the  normal  ureter  it  may 
catch  again  at  15  cm.,  where  the  ureter  crosses  the  pelvis;  or  between 
20  and  25,  where  it  enters  the  kidney  pelvis.  One  must  remember, 
however,  that  the  mere  contact  of  the  ureter  catheter  always  abrades 
the  ureter  wall.  This  abrasion  is  disclosed  by  the  ureteral  epithelia 
that  are  always  seen  in  specimens  -obtained  by  ureter  catheter.  There- 
fore the  catheter  should  be  passed  up  the  ureter  with  utmost  gentle- 
ness and  without  the  least  haste,  so  that  the  canal  may  be  given  oppor- 
tunity to  mold  itself  to  the  rather  stiff  instrument. 

Drawing  Urine — If  no  impediment  has  been  encountered  the 
catheter  is  inserted  between  25  and  30  cm.  Its  tip  is  then  in  the  renal 
pelvis  and  it  should  promptly  begin  to  emit  a  constant  succession  of 
drops.  The  first  ten  or  fifteen  should  be  discarded,  as  these  represent 
bladder  content  that  has  been  carried  up  the  ureter  within  the  lumen 
of  the  cath-eter.  After  they  have  flowed  away,  a  sterile  test  tube  is 
applied  to  the  outer  end  of  the  catheter  and,  while  this  is  collecting 
urine  from  the  kidney,  the  ureter  catheter  is  pushed  in  1  or  2  cm.  to 
give  sufficient  slack,  and  the  cystoscope  is  turned  to  follow  the  inter- 
ureteric  bar  until  it  reaches  the  opposite  ureter.  The  second  catheter 
is  pushed  in  and  the  second  ureter  catheterized.  With  the  two  catheters 
thus  placed  in  the  kidney  pelvis,  before  removing  the  cystoscope,  the 
rate  of  flow  is  contemplated  and  if  either  catheter  appears  to  be  de- 
livering urine  with  abnormal  velocity,  this  is  noted;  and  no  further 
move  is  made  until  the  flow  shall  have  become  more  normal.  Thus  any 
retained  urine  in  the  renal  pelvis  is  emptied  out  and  one  estimates 
the  amount  of  retention.  But  the  mere  fact  of  a  rapid  flow  of  urine 
does  not  of  itself  prove  retention.  It  may  be  due  to  reflex  polyuria 
in  a  normal  kidney. 

If  either  one  of  the  ureter  catheters  has  not  reached  the  renal  pelvis 
the  cystoscope  will  be  kept  in  place  until  one  is  satisfied  that  this 


70  URETER  CATHETERISM 

catheter  is  functionating  regularly.  The  catheter  in  the  ureter  should 
emit  from  three  to  six  or  eight  drops  of  urine  in  rapid  succession  with 
intervals  of  from  two  to  ten  seconds.  If  it  does  not  do  so  it  should  be 
withdrawn  a  trifle,  and  if  this  does  not  help,  an  injection  of  one  or 
two  c.c.  of  water  may  be  made  into  it.  The  gi'eat  objection  to  this 
maneuver,  however,  is  that  it  invalidates  one  of  the  few  absolute,  de- 
pendable data  (urea  per  cent)  obtained  by  the  ureter  catheter.  If 
one  ureter  has  not  been  entered  at  all  the  corresponding  ureter  catheter 
may  be  simply  introduced  into  the  bladder  so  as  to  draw  the  urine  from 
the  uncatheterized  side. 

Removal  of  the  Cystoscope — The  cystoscope  should  not  be  removed 
until  enough  urine  has  been  obtained  from  each  ureter  (if  each  ureter 
has  been  catheterized)  to  permit  microscopical  examination  and  urea 
estimation. 

1.  The  first  step  is  to  turn  the  cystoscope  with  its  lens  upward  and 
then  to  push  the  ureter  catheters  in  so  that  they  coil  up  in  the  bladder 
and  leave  little  more  than  a  centimeter  projecting  from  the  catheter 
channels  at  the  ocular  end  of  the  cystoscope. 

2.  The  second  step  is  the  removal  of  the  telescope.  This  is  first 
unlocked  (after  a  glance  to  be  sure  that  the  lever  is  not  elevated)  then 
withdrawn  2  or  3  cm.  The  protruding  tips  of  the  ureter  catheters  are 
then  pushed  sharply  inward.  This  makes  the  catheter  curve  up  from 
its  bed  alongside  the  telescope.  It  is  thus  readily  disengaged  and  the 
telescope  fully  withdrawn. 

3.  The  third  step  consists  in  emptying  the  bladder  through  the 
sheath.  During  the  withdrawal  of  the  telescope  the  fluid  has  been 
gushing  from  the  bladder.  The  few  remaining  drops  are  quickly  emp- 
tied out  while  the  ureter  catheters  are  being  pushed  in  still  further, 
until  their  tips  are  flush  with  the  outer  edge  of  the  sheath. 

4.  The  final  step  is  the  withdrawal  of  the  sheath.  With  its  beak 
turned  upward  this  maneuver  is  gently  performed.  If  the  beak  is 
inclined  to  hold  the  ureter  catheters  and  to  draw  them  out  this  is  in 
some  measure  prevented  by  pressure  upon  the  catheters  in  the  bulbous 
urethra  as  soon  as  the  tip  of  the  beak  has  vacated  that  part  of  the 
canal. 

Collection  of  Urine. — As  soon  as  the  cystoscope  is  out  the  inter- 
rupted collection  of  urine  is  resumed.  The  catheters  have  perhaps 
been  pulled  out  of  the  kidney  pelvis  so  that  their  flow  is  no  longer  con- 
tinuous, drop  by  drop,  but  comes  in  interrupted  spurts.  Perhaps 
one  of  them  has  been  moved  to  a  place  where  it  does  not  work  well. 
If  so,  one  occupies  a  minute  or  two  in  making  the  patient  comfortable, 
taking  the  feet  off  the  stirrups,  etc.,  and  waits  for  the  catheter  to  work. 
If  it  remains  dry  it  may  be  withdrawn  tentatively  bit  by  bit  until 
it  is  no  more  than  10  or  15  cm.  up  the  ureter  (this  brings  the  25  cm. 


CATHETERISM  OF  THE  NORMAL  URETER         71 

mark  to  the  vulva;  the  40  cm.  mark  to  the  male  meatus).  If  one 
catheter  remains  dry  in  this  situation  its  eyes  are  probably  covered  by 
blood  clot,  epithelia  or  purulent  shreds,  collected  during  its  too  hasty 
introduction.  These  must  be  dislodged  by  a  quick  injection  of  two  c.c. 
of  sterile  water.  These  injections  may  have  to  be  repeated.  If  the 
injected  fluid  itself  does  not  return  one  may  as  well  remove  the  cath- 
eters from  the  ureters.  If  approximately  all  injected  fluid  returns  one 
may  hope  that  urine  will  follow.  If  it  does  not  the  catheter  is  with- 
drawn into  the  bladder.  Several  of  these  to-and-fro  injections  may 
be  required  to  make  the  catheter  work  properly.  Unless  the  patient 
is  very  sensitive,  or  greatly  alarmed  at  any  further  manipulations,  it  is 
usually  better  to  employ  a  number  10  or  12  woven  urethral  catheter 
in  the  bladder  rather  than  the  ureter  catheter ;  or  the  bladder  may  be 
emptied  by  catheter  immediately  after  withdrawal  of  the  remaining 
ureter  catheter. 

Whatever  the  final  arrangements,  the  separate  urines  are  collected 
in  two  properly  labeled  sterile  tubes.  As  soon  as  the  rhythmic  flow 
of  urine  from  each  side  has  been  assured  an  intravenous  injection  of 
one  c.c.  of  standard  six  per  cent  phenolsulphonephthalein  solution  is 
administered.  The  time  of  injection  is  noted  and  a  white  enamel  dish 
is  moistened  with  a  few  drops  of  sodium  hydrate  solution  (or  any  other 
alkali).  After  two  minutes  have  gone  by,  a  drop  of  urine  from  each 
catheter  is  permitted  to  fall  into  this  dish.  This  is  repeated  every 
half  minute  until  the  characteristic  crimson  color  is  obtained  (page 
78)  ;  then  the  catheters  are  transferred  to  two  fresh  bottles,  and  the 
urine  for  phenolsulphonephthalein  test  is  collected  in  these.  The  dura- 
tion of  this  collection  may  be  varied  with  advantage.  For  cases  with 
marked  disparity  in  kidney  function  five  minutes  may  be  enough;  ten 
minutes  is  Ibng  enough  for  the  average  case ;  and  fifteen  minutes  for 
any  case.  If  the  urines  are  to  be  collected  for  a  longer  time  than  this 
the  oversight  is  sooner  or  later  delegated  to  an  assistant.  This  spells 
disaster.  For  throughout  the  examination  the  constant  action  of  the 
ureter  catheter  must  be  controlled  by  a  no  less  watchful  and  intelligent 
eye  than  that  of  the  operator  himself. 

After  enough  urine  has  been  collected  for  phenolsulphonephthalein 
examination  one  has  obtained  through  the  physical  and  urinary  analyses 
and  history,  through  the  data  obtained  by  cystoscopy  and  those  noted 
in  the  urines  as  they  flow  from  the  ureter  catheters,  a  general  idea  of 
the  need  for  any  further  specimens  to  be  used  for  guinea-pig  inocula- 
tion, or  for  cultivation  of  bacteria.  These  should  be  collected  last,  and 
if  the  catheters  h-ave  been  sterilized  by  formalin,  specimens  for  culture 
should  be  dropped  directly  into  the  culture  tube,  otherwise  the  amount 
of  formalin  may  be  enough  to  inhibit  growth.  The  formalin  does  not 
inhibit  the  growth  of  the  tubercle  bacilli. 


72  UEETER  CATHETERISM 

Further    Observations    Throug-h    the    Ureter    Catheter ^By   this 

time  the  patient  usually  feels  that  he  has  had  enough.  Such  manipu- 
lations as  the  measuring  of  the  capacity  of  the  kidney  pelvis  hy  injec- 
tion, or  injection  for  pyelography  had  better  be  reserved  for  a  subse- 
quent cystoscopy. 

Withdrawal  of  the  Catheters — The  gi-eat  advantage  of  the  formalin 
sterilization  of  catheters  is  the  assurance  that  they  will  not  transmit 
infection  from  the  urethra  or  the  bladder  into  the  ureter.  If  they 
are  gently  introduced  so  as  not  to  produce  trauma  they  can  do  no  serious 
harm.  If  using  catheters  that  are  merely  aseptic,  I  should  prefer  to 
close  the  examination  by  the  injection  of  tvro  c.c.  of  one  per  cent  silver 
nitrate  into  each  ureter.  As  the  catheters  are  withdrawn  into  the 
bladder  an  injection  of  silver  nitrate  1:  5,000  should  be  made  through 
one  of  them  into  the  bladder. 

Aftertreatment. — If  the  patient  has  been  badly  frightened,  or  suf- 
fered much  pain,  morphin  should  be  administered  by  mouth  or  hypo- 
dermic, and  he  should  lie  still  for  at  least  half  an  hour  before  attempt- 
ing to  leave  the  office.  Cases  from  whom  trouble  is  anticipated  should 
always  be  examined  in  a  hospital,  and  in  any  case  the  patient  should 
be  informed  beforehand  that  he  is  to  cancel  all  engagements  for  the 
rest  of  the  day,  and  for  the  next  day  too ;  unless  a  previous  cystoscopy 
has  proven  that  he  is  not  likely  to  be  greatly  disturbed  by  the  examina- 
tion. The  patient  who  is  cystoscoped  repeatedly  usually  becomes  so 
insensitive  that  anesthesia  may  be  dispensed  with.  Each  successive 
cystoscopy  of  patients  who  require  numerous  examinations  proves  the 
importance  of  the  nervous  element  in  their  pain. 

Variations  in  Technic. — ^We  have  described  the  method  we  employ 
in  catheterizing  ureters,  but  the  variations  in  technic  of  different  oper- 
ators are  extreme.  In  conjunction  with  or  in  place  of  phenolsulphone- 
phthalein  and  urea  estimation,  one  may  employ  any  renal  function  test 
described  in  the  next  chapter.  One  may  follow  Albarran.  and  leave 
the  catheters  in  the  ureter  from  an  hour  and  a  half  to  two  hours; 
or  Geraghty,  and  leave  them  in  half  an  hour  to  an  hour.  Or  at  the 
other  extreme  one  may  follow  Braash  who  uses  a  direct  vision  cysto- 
scope,  scorns  all  renal  functional  tests  and  does  not  even  estimate  the 
percentage  of  urea. 


URETER  CATHETERISM  OF  THE  DISEASED  URETER 

Perhaps  the  most  important  consideration  in  catheterizing  the  dis- 
eased ureter  is  that  any  accident  of  catheterization,  such  as  interfer- 
ence with  passage  of  the  catheter  by  obstruction,  or  interference  with 
the  flow  of  urine  by  blood  clot  may  occur  quite  as  readily  in  the  normal 


FINDING  THE  URETER  MOUTH  73 

as  in  the  diseased.      The  fact  that  a  ureter  catheter  is  arrested  or 
obstructed  does  not  tell  us  what  the  obstruction  is. 

One  should  closely  observe  the  flow  of  urine  through  the  catheter. 
If  this  is  properly  placed  in  a  normal  kidney  pelvis  the  urine  comes 
slowly  but  regTilarly  drop  by  drop.  (If  the  patient  has  nervous  polyuria 
it  flows  rapidly.)  When  properly  placed  in  the  normal  ureter  the 
urine  comes  in  an  intermittent  succession  of  a  number  of  drops  as 
described  above.  If  improperly  placed  either  in  the  pelvis  or  in  the 
ureter  the  regTilarity  of  the  flow  can  be  considered  only  under  two 
conditions : 

1.  With  the  catheter  in  the  kidney  pelvis  there  comes  first  of  all  a 
very  rapid  dribbling  of  urine,  which  empties  out  an  accumulation  of 
urine  in  the  pelvis;  then  the  rapidity  of  the  flow  diminishes.  But 
thereafter  this  urine  continues  to  show  a  relative  dilution  in  com- 
parison to  that  from  the  opposite  kidney.     This  is  hydronephrosis. 

2.  With  the  catheter  in  the  ureter  and  the  bladder  empty  the  flow 
continues  as  though  it  were  in  the  pelvis ;  this  means  dilatation  of  the 
ureter,  and  loss  of  its  peristaltic  action.  Such  a  diagnosis  should  be 
confirmed  by  pyelography.  It  indicates  dilatation  of  the  ureter  down 
to  the  point  where  the  eye  of  the  catheter  rests,  and  hydronephrosis 
above. 

Inspection  of  the  urine  obtained  by  ureter  catheter  is  often  most 
misleading.  The  urine  may  be  clouded  by  epithelial  cells;  it  may 
be  bloody,  though  the  ureter  and  kidney  are  entirely  normal.  The 
urine  should  therefore  always  be  examined  by  microscope. 

The  collection  of  urine  should  usually  be  delayed  until  the  bladder 
is  emptied ;  for  the  chronically  diseased  ureter  may  permit  reflux  of 
fluid  from  the  bladder,  which  returns  through  the  catheter  in  a  con- 
tinuous stream  until  the  bladder  is  empty. 


FINDING  THE  URETER  MOUTH 

Inflammation  or  cicatrization  may  make  the  ureter  mouth  much 
more  prominent  than  when  it  is  normal ;  or  surrounding  inflammation 
or  ulceration  may  quite  conceal  it,  or  retract  it  to  an  unsuspected  posi- 
tion. Under  these  circumstances  successful  catheterization  of  the 
ureter  requires  the  instinct  born  of  experience,  for  it  depends  upon 
the  rapidity  of  the  finding  of  the  orifice,  or  upon  catheterization  with- 
out actually  seeing  the  orifice  until  the  catheter  enters  it.  The  be- 
ginner who  has  to  find  the  ureter  by  laboriously  tracing  landmarks  tliat 
are  all  but  obliterated,  cannot  succeed  as  does  the  expert  who  imme- 
diately places  his  cystoscope  in  approximately  the  correct  position,  rec- 
ognizes the  place  where  the  ureter  should  be  found,  and  is  able  to  enter 


74  URETER  CATHETERISM 

the  ureter  by  projecting  his  catheter  in  what  he  considers  the  right 
direction,  even  though  the  orifice  is  quite  invisible. 

Intravenous  injection  of  indigocarmin  (p.  78)  is  an  invaluable  aid 
in  finding  the  ureter  mouth  in  difficult  cases. 


CHAPTEK    VIII 

ESTIMATION  OF  THE  RENAL  FUNCTION 

Estimation  of  the  renal  function  forms  an  important  element  in  the 
diagiiosis  of  almost  every  disease  of  the  urinary  organs.  Yet  no 
method  of  estimating  this  function  can  claim  to  be  wholly  accurate  or 
all  embracing.  Hence,  perhaps,  the  accumulated  confusion  resulting 
on  the  one  hand  from  over-enthusiastic  praise  of  some  one  method, 
and  on  the  other  from  undue  pessimism  in  regard  to  all.  Any  attempt 
at  exhaustive  evaluation  of  all  the  methods  advocated  at  home  and 
abroad  would  but  add  to  this  confusion.  We  shall  rest  satisfied  with  a 
description  of  the  methods  employed  by  the  majority  of  American 
urologists  today. 

To  this  end  we  make  two  postulates : 

1.  In  the  first  place,  the  following  description  refers  exclusively  to 
surgical  diseases  of  the  kidney.  ]S[on-bacterial  chronic  nephritis  does, 
it  is  true,  frequently  complicate  the  clinical  picture  of  surgical  renal 
disease  (infection,  retention,  tumor)  ;  but  the  tests  that  most  accu- 
rately measure  the  renal  function  in  the  latter  class  of  cases  are 
singularly  inaccurate  in  "medical"  cases.  Furthermore,  the  test  of 
renal  function  in  Bright's  disease  is  at  once  so  complicated  in  its 
technic  and  so  indefinite  in  its  conclusions  that  we  feel  doubly  justified 
in  neglecting  it.^ 

2.  In  the  second  place,  in  the  interests  of  brevity  and  lucidity  we 
must  take  for  granted  a  comprehension  of  renal  physiology  and  also 
omit  a  description  of  many  of  the  methods  of  estimating  renal  func- 
tion. Among  these  methods  many  have  so  definite  a  value  that  a  brief 
excuse  for  this  omission  is  called  for. 

Thus  "Ambard's  constant,"  so  much  lauded  by  the  French,  is  not 
used  in  the  United  States.  It  lacks  supreme  accuracy;  it  requires  a 
relatively  complex  series  of  observations. 

Estimation  of  the  freezing  point,  whether  of  blood  or  urine,  has 
similar  defects.  (The  freezing  point  of  any  solution,  be  it  noted, 
measures  the  number  of  its  molecules,  while  the  specific  gravity 
measures  their  weight.) 

The  nitrogen  estimation  when  applied  to  urine  gives  no  greater 

^Cf.  Christian,  Frothingham,  O'Hare  and  Woods,  Am.  Jour.  Med.  Sci.,  Nov., 
1915. 

75 


76  ESTIMATION  OF  THE  RENAL  FUNCTION 

accuracy  than  urea  estimation.  When  applied  to  blood  it  is  doubtless 
more  accurate  than  the  freezing  point;  but  its  superiority  is  not  fully 
proven.     It  should  be  used  to  control  other  tests. 

Experimental  polyuria  and  oliguria  are  but  practical  applications 
of  the  lack  of  adaptability  so  characteristic  of  the  diseased  kidney, 
and  upon  which  we  shall  have  occasion  to  insist.  Indeed  a  study  of 
this  phenomenon  forms  a  part  of  many  of  our  observations.  But 
nothing  is  to  be  gained  by  formal  observance  of  the  details  either  of 
experimental  polyuria  or  of  experimental  oliguria. 

Phlorizin,  methylene  blue,  and  many  other  substances  employed  for 
"artificial  elimination"  tests  have  all  been  eclipsed  by  phenolsulphone- 
phthalein. 

Intravenous  injection  of  indigocarmin  for  meatoscopy  has  a  definite 
value. 

THE  IMPAIRED  RENAL  FUNCTION 

With  these  postulates  granted  let  us  survey  the  two  striking  char- 
acteristics of  the  impaired  renal  function.     These  are: 
Diminished  excretion  of  solids. 
Lack  of  flexibility. 

DIMINISHED  EXCTRETION  OF  SOLIDS 

Excretion  of  excrementitious  solids  in  watery  solution  is  the  car- 
dinal function  of  the  kidney.  The  gravity  of  any  disease  of  this 
organ  is  measured  best  in  terais  of  lack  of  efficiency  in  this,  its  excre- 
tory function.  But  this  function  is  a  very  complex  one.  ]^o  test  or 
combination  of  tests  measures  it  with  precision.  Yet,  as  already  noted, 
impairment  of  excretory  function  by  infection  is  measured  with  a  fair 
degree  of  accuracy  by  the  excretion  of  urea  (a  little  less  accurately  by 
specific  gravity,  a  little  more  so  by  urine  and  blood  nitrogen  and 
freezing  point),  and  by  the  phenolsulphonephthalein  test. 

Urea  Estimation. — So  overshadowed  is  urea  by  phenolsulphone- 
phthalein that  there  is  a  general  tendency  on  the  part  of  urologists  to 
omit  altogether  the  collection  of  24-hour  specimens  of  urine  for  quanti- 
tative tests.  But  the  24:-hour  specimen  should  be  depended  upon  for 
two  data:  viz.,  the  total  quantity  of  urine  passed,  and  the  concentra- 
tion and  total  quantity  of  urea. 

The  total  quantity  of  urine,  if  between  1,000  and  2,000  c.c,  does 
not  tell  us  much ;  but  it  exceeds  these  limits  only  because  of  an  unusual 
excess  or  diminution  of  the  intake  of  fluids,  excessive  perspiration  or 
an  impainnent  of  kidney  function. 

Pathological    oliguria   may   mean    obstruction   to    the   outflow   of 


THE  IMPAIRED  RENAL  FUNCTION  77 

urine,  acute  congestion  of  the  kidney  (as  in  acute  Briglit's),  or  grave 
chronic  impainnent  of  kidney  function.  These  conditions  may  be 
readily  distinguished  hy  colhitoral  investigation. 

Polyuria  is  characteristic  of  certain  types  of  chronic  renal  con- 
gestion, as  in  tuberculosis,  stone,  prostatism,  retention  (q.  v.).  The 
polyuria  of  nervousness,  of  arteriosclerosis,  and  other  nonsurgical  con- 
ditions do  not  concern  us. 

The  total  quantity  of  urea  passed  for  24  hours  should  exceed  45  gTQ. 
(50  gm.  is  regarded  as  normal).  Physiological  variations  in  the  total 
urine  do  not  materially  affect  the  total  urea.  But  disease  of  the  kidney 
reduces  it.  The  diminution  of  total  urea  is  not,  however,  a  good 
index  of  renal  disease.  ISTeurasthenia,  for  instance,  may  reduce  it  to 
30  gtn.,  or  even  less. 

The  concentration  of  urea  (gm.  per  liter)  is  in  one  sense  an  indi- 
cation of  health.  For  the  diseased  kidney  shows  its  reduction  of  func- 
tion very  largely  by  its  inability  to  excrete  solids.  Hence  the  concen- 
tration of  urea  by  a  diseased  kidney  is  always  relatively  low.  There 
are  many  physiological  agencies  that  interfere  with  urea  concentra- 
tion. Thus  a  very  dilute  urine  may  be  passed  as  the  result  of  nervous- 
ness, or  of  drinking  large  quantities  of  fluid,  or  of  arteriosclerosis,  quite 
independently  of  the  condition  of  the  kidney  itself.  Hence  lach  of 
urea  concentration  is  7io  evidence  in  itself  of  disease  of  the  kidney.  On 
the  other  hand,  the  presence  of  urea  concentration  is  an  evidence  of 
health  of  the  kidney.  A  urea  concentration  of  more  than  18  or  20  gm. 
to  the  liter  is  evidence  of  a  sound  kidney.-^ 

But  urea  estimation  of  the  specimens  obtained  separately  from 
the  two  kidneys  by  the  ureter  catheter  is  of  the  greatest  value.  The 
urine  passed  simultaneously  by  two  normal  kidneys  should  show  a 
urea  concentration  which  is  either  absolutely  equal  or  varying  not 
more  than  5  per  cent  (i.e.,  1  gm.  in  20).  But  urea  variations  are 
subject  to  unaccountable  physiological  changes  and  are  in  general  less 
marked  than  the  corresponding  variations  in  phenolsulphonephthalein 
output. 

In  view  of  the  inaccuracy  of  quantitative  ureter  catheter  findings 
it  is  prudent  to  consider  urea  percentage  "  much  more  accurate  than 
urea  volume  or  phenolsulphonephthalein  percentage.  If  they  all 
agree,  or  if  the  urea  volume  or  the  phenolsulphonephthalein  percentage 
vary  in  the  same  sense,  but  to  a  different  degree  from  urea  percentage, 
the  accuracy  of  the  observation  is  confirmed.     But  if  they  disagree,  we 

^Yet  a  patient  of  mine  died  of  acute  renal  congestion  53  hours  after  nephrec- 
tomy, having  passed  about  600  c.c.  of  urine,  one  portion  of  wliicli  showed  a  concen- 
tration of  urea  amounting  to  33  gm.  to  the  liter. 

"  Which  is  the  only  observation  not  vitiated  by  the  leakage  of  urine  alongside 
the  ureter  catheter. 


78  ESTIMATION  OF  THE  RENAL  FUNCTION 

may  have  grave  doubts  as  to  whether  some  technical  error  has  not 
vitiated  our  conclusions. 

Indigocarmin — Indigocarmin  should  never  be  injected  in  suspen- 
sion, as  is  usually  done.  Furness  has  shown  that  10  c.c.  of  a  saturated 
solution  (0.6  per  cent)  injected  intravenously  appears  in  the  urine 
from  a  normal  kidney  within  six  minutes  and  colors  the  urine  a  deep 
blue  or  gTeen  for  less  than  half  an  hour  thereafter.  Hence  in  case  the 
ureter  mouth  cannot  be  found  or  the  ureter  cannot  be  catheterized, 
the  dark  stream  of  urine  shows  the  position  of  the  ureter  mouth,  the 
regTilarity  and  force  of  ureteral  peristalsis  and,  with  relative  accuracy, 
the  efficiency  of  the  kidneys  (measured  by  the  relative  darkness  of 
the  ureteral  jets).  The  cystoscope  should  not  be  introduced  until  the 
dye  has  been  injected  and  is  visible  in  the  urine.  If  the  ureter  is  thus 
found  and  catheterized,  phenolsulphonephthalein  may  be  injected  and 
its  output  estimated.  For  alkalinization  of  the  urine  decolorizes  the 
indigocarmin. 

Indigocarmin  is  not  so  convenient,  and  probably  not  so  accurate, 
as  phenolsulphonephthalein  for  mathematical  estimation  of  impair- 
ment of  the  kidney  function. 

Phenolsulphonephthalein — It  has  been  objected  that  no  artificial 
elimination  test  can  equal  urea  estimation  of  kidney  function  because 
the  kidney  naturally  eliminates  urea,  and  does  not  naturally  eliminate 
other  substances.  The  only  answer  to  such  an  argument  is  that  the 
wide  experience  of  many  observers  has  led  to  an  almost  unanimous 
consensus  of  opinion  to  the  effect  that  the  phenolsulphonephthalein 
output  usually  gives  more  accurate  evidence  of  kidney  function  or 
impairment  of  function  than  any  other  test.  We  repeat  that  this  refers 
only  to  surgical  cases.  The  phenolsulphonephthalein  test  is  notoriously 
inaccurate  in  medical  cases. 

The  test  was  introduced  by  Drs.  Kowntree  and  Geraghty.^  The 
apparatus  required  is  a  6  per  cent  solution  of  phenolsulphonephthalein ; 
this  is  sold  in  1  c.c.  ampules.  One  also  requires  a  colorimeter.  The 
Dubosc  colorimeter  is  much  the  most  accurate;  but  its  readings  are 
unnecessarily  accurate,  i.e.,  the  reading  is  more  precise  than  is  war- 
ranted by  the  test.  The  Dunning  colorimeter,  though  it  permits  errors 
of  two  or  three  per  cent  in  the  reading,  is  cheaper  than,  and  fully  as 
accurate  as,  any  other  for  practical  purposes.  The  Hellige  colorimeter, 
though  practically  no  more  accurate,  is  more  expensive. 

The  kidney  function  of  a  healthy  person,  known  to  empty  his 
bladder,  is  estimated  as  follows:  1  c.c.  of  the  solution  is  injected  into 
the  muscle  of  the  lumbar  or  gluteal  region.  The  time  of  injection  is 
noted  precisely.     Ten  minutes  later  the  patient  is  made  to  urinate. 

^Jour.  of  Pharmacol,  and  Exp.  Therap.,  July,  1910.  Cf.  also  Keyes  and  Stevens, 
Am.  Jour,  of  Urol,  Oct.,  1911,  vii,  367,  and  N.  Y.  Med.  Jour.,  June  1,  1912. 


THE  IMPAIRED  RENAL  FUNCTION  79 

If  tlie  renal  function  is  normal  the  phenolsulphoneplitlialein  output 
will  have  just  begun,  and  the  urine  (if  acid)  will  be  of  an  abnormally 
bright  yellow  color.  The  addition  of  a  few  drops  of  sodium  hydrate 
solution,  or  other  alkali,  to  this  urine  changes  its  color  to  a  bright 
cerise. 

One  hour  later  the  patient  urinates  again.  This  urine  is  diluted 
to  1  liter  and  a  few  drops  of  5  per  cent  sodium  hydrate  solution 
added  to  it  render  the  urine  alkaline  and  bring  out  the  cerise  color. 
The  urine  is  then  poured  into  the  ampule  provided,  and  measured  in 
the  colorimeter.  At  the  end  of  a  second  hour  the  patient  urinates 
again,  and  the  urine  thus  obtained  is  alkalinized  and  measured  in  the 
same  way. 

It  will  be  found  that  the  normal  kidney  begins  to  excrete  phenol- 
sulphoneplitlialein within  ten  minutes,  eliminates  at  least  40  per  cent 
of  the  amount  injected  within  one  hour  (usually  50  per  cent  or  more), 
and  in  the  second  hour  10  or  20  per  cent  more.  The  normal  total  for 
two  hours  is  at  least  50  per  cent ;  it  is  usually  60  to  70  per  cent,  and 
may  rise  as  high  as  80  per  cent.  Rowntree  and  Geraghty  insist  that 
the  patient  shall  drink  several  glasses  of  water  during  the  test.  This 
has  the  advantage  of  filling  the  bladder  with  enough  water  to  insure 
the  patient's  ability  to  urinate  at  the  end  of  each  hour. 

The  following  precautions  are  to  be  noted  in  reference  to  patho- 
logical cases: 

1.  If  the  urine  contains  much  pus  it  will  become  very  ropy  on 
addition  of  the  alkali.  Therefore  the  alkali  should  not  be  added  until 
after  the  urine  has  been  diluted.  The  dye  is  diluted  with  the  urine- 
and  the  resulting  ropiness  does  not  interfere  with  the  correct  estimation. 

2.  Blood  in  the  urine  is  a  rather  serious  impediment  to  exact 
estimation.  _  Nevertheless,  if  the  urine  is  permitted  to  stand  for  a  while 
before  being  diluted,  the  blood  corpuscles  will  settle  to  the  bottom  of 
the  glass,  and  the  supernatant  fluid  may  then  be  used  with  a  fair 
degree  of  accuracy. 

3.  If  the  patient  does  not  empty  his  bladder,  it  is  of  course  neces- 
sary to  catheterize. 

4.  If  the  output  of  phenolsulphoneplitlialein  is  much  delayed,  it 
may  be  found  that  it  does  not  appear  in  the  urine  at  all  for  half  an 
hour  or  even  an  hour  after  injection  (even  longer  delay  sometimes 
occurs,  but  in  that  case  the  total  output  in  any  one  hour  is  never  more 
than  a  trace).  In  such  cases  the  output  for  the  first  hour  is  usually 
approximately  the  same  as  that  of  the  succeeding  hours.  Most  excep- 
tionally the  kidneys  delay  the  output  of  phenolsulplionephthalein  as 
long  as  an  hour  or  so  and  then  excrete  a  relatively  high  percentage 
(as  much  as  35  per  cent  even)  in  the  first  hour,  and  very  little  in  the 
succeeding  hours.    In  such  cases  the  delay  in  output  of  phenolsulphone- 


80  ESTIMATION  OF  THE  RENAL  FUNCTION 

phthalein  is  not  nearly  so  significant  of  bad  function  as  the  ability 
to  concentrate  the  drug,  when  it  is  excreted,  is  evidence  of  good 
function.  Consequently  in  such  instances  it  is  well  to  repeat  the  test, 
if  it  has  been  done  by  the  routine  method,  watching  for  the  precise 
moment  of  excretion,  and  measuring  the  first  hour  from  that  time. 

Phenolsulphonephthalein  estimations  are,  of  course,  comparable  not 
to  percentages  of  urea,  but  to  total  urea,  i.e.,  to  the  amount  of  urea 
excreted  in  grams  during  a  certain  period.  Thus  we  must  always 
bear  in  mind  that  quantitative  inaccuracies  in  the  amount  of  urine 
passed  (such  as  result  for  instance  from  retention  of  some  urine  in 
the  bladder  or,  when  the  ureter  catheter  is  employed,  from  extra- 
catheter  flow)  introduce  no  inaccuracy  in  the  estimation  of  urea  per- 
centage, but  do  introduce  an  unknown  element  of  inaccuracy  in  the 
estimation  of  total  urea  and  of  phenolsulphonephthalein  percentage. 
Thus  the  urea  percentage  is  that  estimation  which  is  the  freest  of  all 
from  the  element  of  technical  error.  But,  apart  from  technical  errors, 
the  phenolsulphonephthalein  output  is  more  sensitive  than  the  urea 
percentage.  On  the  other  hand,  phenolsulphonephthalein  does  rather 
magnify  the  loss  of  kidney  function,  and  exceptionally  the  phenolsulpho- 
nephthalein output  is  very  low  although  the  kidney  function  is  seem- 
ingly little  impaired.  I  have,  for  instance,  reported  ^  a  case  of  urethral 
stricture  who  entered  Bellevue  Hospital  in  acute  retention.  I  promptly 
performed  perineal  section  without  a  guide  under  ether.  The  next 
day,  and  several  times  during  the  next  few  weeks,  he  excreted  only  a 
trace  of  red  in  twenty-four  hours.  Yet  he  had  no  untoward  symptoms. 
He  remained  in  the  hospital  for  a  number  of  months.  During  that 
time  he  was  twice  given  a  spinal  anesthetic,  once  for  a  Cabot  resection 
of  the  urethra,  once  for  a  Chetwood  operation  on  the  neck  of  his 
bladder,  and  finally  the  resulting  fistula  was  closed  under  a  local 
anesthetic.  Yet  during  all  this  time  he  never  showed  more  than  5  per 
cent  of  phenolsulphonephthalein  in  one  hour,  and  during  the  gTeater 
part  of  the  time  he  passed  but  a  trace  of  the  drug  in  the  first  twelve 
hours  after  its  injection.^  Such  a  low  phenolsulphonephthalein  output 
is  usually  prohibitive  of  surgical  interference.  But  the  case  is  cited 
as  showing  that  in  some  instances  one  may  disregard  a  low  phenol- 
sulphonephthalein output  if  all  other  signs  point  to  a  favorable  general 
condition  (and  especially  if  the  blood  urea  is  low). 

Although  the  phenolsulphonephthalein  output  is  expressed  accu- 
rately in  figures,  these  figures  do  not  read  the  same  for  one  case  as 
for  another.  The  patient  is  a  human  being,  not  an  inanimate  object. 
Other  things  must  be  taken  into  consideration  as  well  as  the  phenol- 
sulphonephthalein output. 

^Am.  Jour,  of  Urol.,  1912,  viii,  No.  11. 
"  He  was  alive  and  at  work  two  years  later. 


THE  IMPAIRED  RENAL  FUNCTION  81 

Beer  has  suggested  that  operation  may  be  safely  performed  upon 
persons  with  a  very  low  phenolsulphonephthalein  output  if  it  can  be 
shown  that  the  gravity  of  the  lesion  in  one  kidney  is  much  more  marked 
than  that  in  the  other.  In  this  case  the  lowered  phenolsulphonephtha- 
lein from  the  relatively  normal  kidney  is  but  a  reflex  phenomenon 
which  might  be  safely  disregarded  in  certain  cases  that  appear  to  be 
otherwise  in  good  health.  I  should  gravely  doubt  my  ability  to  apply 
such  a  rule  in  practice  with  any  degree  of  success.  Not  only  have  I 
operated  upon  persons  with  extremely  low  phenolsulphonephthalein 
output,  but  I  have  seen  at  least  one  patient  die  of  acute  renal  conges- 
tion immediately  after  operation  although  the  phenolsulphonephthalein 
before  operation  had  been  high.  In  this  case,  the  high  output  before 
operation  was  justified  by  the  post  mortem  appearance  of  the  kidney, 
but  the  shock  of  operation  was  too  much  for  the  patient  to  bear. 

Such  exceptions  in  the  interpretations  of  the  phenolsulphonephtha- 
lein output  will  continue  to  occur.  They  are  due  to  two  factors.  The 
test  itself  doubtless  fails  to  indicate  the  precise  general  renal  function 
in  certain  surgical  cases,  just  as  it  does  in  many  medical  cases.  But 
the  more  usual  reason  for  its  failure  is  that  the  surgeon's  question  is 
not — what  is  the  kidney  function  at  the  present  time  but  rather,  what 
will  the  kidney  do  if  I  operate  ? 

This  question  involves  many  elements  that  no  single  test  can  cover. 
It  is  a  question  that  can  only  be  answered  out  of  the  broad  experience 
of  the  surgeon.  The  phenolsulphonephthalein  test  forms,  for  many  of 
us,  an  essential  element  in  this  answer.  A  high  output  of  the  dye  is 
most  reassuring;  a  low  output  may  be  due  to  errors  of  technic,  to  dis- 
ease in  the  kidney  or  to  obscure  causes  that  we  cannot  understand. 
But  in  many  cases  of  obscure  surgical  disease  of  the  kidney,  the  marked 
lowering  of  phenolsulphonephthalein  output  is  the  only  clear  indica- 
tion that  the  kidney  is  gravely  impaired,  and  will  doubtless  not  with- 
stand the  shock  of  general  anesthesia  and  operation.  One  of  the  chief 
functions  of  the  phenolsulphonephthalein  test  is  therefore  to  act  as  a 
danger  signal.  Though  what  has  just  been  said  suggests  the  peril  of 
attempting  a  too  precise  definition,  the  following  figures  may  be  accepted 
as  roughly  accurate. 

In  one  hour  after  the  onset  of  phenolsulphonephthalein  excretion 
following  intramuscular  injection  40  per  cent  or  more  is  a  noimal 
excretion;  25  per  cent  or  more  shows  moderate  impairment  of  func- 
tion; if  less  than  20  per  cent  is  excreted  in  one  hour,  the  impairment 
of  function  is  probably  very  gTave.  A  low  excretion,  due  to  tuber- 
culosis or  to  acute  renal  congestion  (notably  that  due  to  the  institution 
of  catheter  life  in  prostatics),  is  particularly  ominous.  But  a  chronic- 
ally low  output,  as  in  the  case  mentioned  above,  is  simply  a  sign  to 
beware. 


82  ESTIMATION  OF  THE  EENAL  FUNCTION 

PlIENOLSULPHONEPHTHALEIN    WITH    THE    UrETEK    CaTHETEK. ^It 

will  be  noted  that  no  mention  has  been  made  of  intravenous  injection  of 
phenolsulphonephthalein  as  a  test  of  kidney  function.  Intravenous  in- 
jection presents  no  advantages  for  routine  work,  and  many  disadvan- 
tages, for  it  concentrates  the  output  so  much  as  markedly  to  increase  the 
possible  technical  error. 

But  other  considerations  control  our  choice  of  method  when  em- 
ploying xhe  ureter  catheter.  In  the  first  place,  speed  is  imperative, 
both  out  of  consideration  to  the  patient,  and  because  the  ureter  catheter 
so  readily  becomes  occluded.  Moreover  many  perfectly  normal  persons 
exhibit,  as  physical  evidence  of  the  nervous  shock  due  to  cystoscopy,  a 
marked  nervous  polyuria.  This  polyuria  is  associated  with  a  marked 
inhibition  of  the  excretion  of  solids.  Under  such  circumstances,  the 
normal  kidney  may  excrete  only  a  trace  of  phenolsulphonephthalein 
if  the  drug  is  injected  intramuscularly.  Intravenous  injection  over- 
comes this  inhibition  by  the  greater  concentration  in  which  the  dye  is 
presented  to  the  kidney.  Hence  intravenous  injection  should  always  he 
employed  in  connection  with  ureter  catheterization. 

The  normal  onset  of  excretion  after  intravenous  injection  and 
measured  by  ureter  catheter  is  from  2  to  6  minutes ;  but  the  intervention 
of  the  catheter  so  multiplies  the  possibilities  of  technical  error  that  the 
time  of  onset  is  merely  a  point  from  which  to  begin  the  collection  of 
urine  for  phenolsulphonephthalein  estimation.  Delay  in  output  beyond 
9  minutes  is  rather  unusual  even  when  the  function  of  the  kidney  is 
impaired. 

There  are  certain  advantages  in  taking  the  phenolsulphonephthalein 
estimation  simultaneously  from  each  kidney  regardless  of  whether  the 
time  of  output  is  markedly  delayed  in  one  of  them  or  not.  For  if  the 
marked  delay  is  not  due  to  stoppage  of  the  catheter  or  extracatheter 
flow  it  may  well  be  counted  as  evidence  against  the  function  of  that 
kidney.  I  have  always  made  the  estimation  simultaneously  on  this 
account. 

The  duration  of  the  collection  of  phenolsulphonephthalein  by  ureter 
catheter  should  be  sufficient  to  give  us  the  information  we  require.  If 
the  output  is  immediate  and  strong  from  each  kidney,  the  experienced 
observer  will  sometimes  consider  5  minutes  long  enough  for  all  his 
needs.  I  usually  collect  the  urine  for  10  or  15  minutes,  personally 
supervising  the  action  of  the  ureter  catheters  throughout  this  time,  so 
that  I  may  have  some  notion  of  the  probable  amount  of  extracatheter 
flow.  This  is  also  checked  up  by  measuring  the  amount  of  urine  ob- 
tained from  each  catheter,  and  noting  the  phenolsulphonephthalein 
content  of  the  urine  in  the  bladder  at  the  moment  that  the  ureter 
catheters  are  withdrawn. 

Each  normal  hidney  excretes  at  least  1  per  cent  of  phenolsulphone- 


THE  IMPAIRED  RENAL  FUNCTION  83 

phthalein  per  minute  for  the  first  20  minutes  after  the  appearance  of 
the  dye  in  the  urine  following  intravenous  injection. 

The  test  as  thus  applied  is  much  more  seusitive  than  urea  estima- 
tion, and  will  be  found  to  vary  much  more  widely.  For  instance,  a 
hydronephrotic  kidney  during  the  15  minutes  after  its  normal  fellow 
had  begim  to  excrete  the  dye,  excreted  no  phenolsulphonephthalein 
whatsoever.  Yet  the  urea  percentage  in  the  urine  excreted  by  this 
kidney  was  0.8  per  cent. 

The  relative  merits  of  the  more  sensitive  phenolsulphonephthalein 
or  the  less  sensitive  urea  are  scarcely  worth  arguing.  The  errors  and 
disturbances  incident  to  cystoscopy  are  such  that  the  only  thing  mathe- 
matically certain  in  the  quantitative  analysis  of  specimens  of  urine 
obtained  by  ureter  catheter  is  that  these  specimens  represent  neither 
the  normal  nor  the  total  function  of  that  kidney  during  a  given  space 
of  time. 

The  object  of  employing  the  phenolsulphonephthalein  test  with 
the  ureter  catheter  is  to  obtain  ready  confirmation  of  the  conclusions 
derived  from  microscopic  analysis  and  urea  estimation  of  the  urines 
obtained  separately  from  the  two  kidneys.  The  most  dependable 
features  of  the  urines  thus  obtained  are  the  micro-analysis  for  pus  and 
bacteria,  and  the  estimation  of  urea  per  cent.  But  the  added  volu- 
metric estimation  of  total  quantity  of  urine,  total  quantity  of  urea,  and 
percentage  of  phenolsulphonephthalein,  strengthen  our  impression  in 
otherwise  doubtful  cases.  When  they  disagree,  and  the  disagreement 
is  not  plainly  explicable  on  grounds  of  technical  error,  the  ureters 
should  again  be  catheterized. 

LACK  OF  FLEXIBILITY 

Barringer  has  justly  observed  that  the  tests  for  renal  function  are 
actually  tests  of  the  reserve  force  of  the  kidney ;  a  reserve  upon  which 
the  surgeon  usually  intends  to  draw  to  withstand  the  shock  of  operation. 
Power  to  take  on  extra  work  (flexibility  in  other  words)  is,  therefore, 
one  of  the  striking  characteristics  of  the  normal  kidney  function.  This 
flexibility  is  manifested  in  changes  from  hour  to  hour,  indeed  from 
minute  to  minute,  in  the  quantity  and  quality  of  the  urine.  The  dis- 
eased kidney  shows  a  marked  diminution  in  this  flexibility.  Such 
ordinary  influences  as  eating  and  drinking,  perspiring,  etc.,  excite  a 
change  in  the  quality  and  quantity  of  its  output  much  less  than  that 
of  its  normal  fellow.  This  lack  of  flexibility  has  been  made  the  founda- 
tion of  various  tests  of  renal  function,  notably  the  experimental  polyuria 
test  of  Albarran.^  He  collected  the  urine  for  four  half-hour  periods, 
administering  three  tumblers  of  water  at  the  end  of  the  first  period. 

*"  Exploration  des  Fonctions  Eenales, "  1905. 


84  ESTIMATION  OF  THE  EENAL  FUNCTION 

The  result  of  his  test  may  be  plotted  in  very  pretty  curves,  but 
its  accuracy  by  no  means  compensates  for  the  length  of  time  con- 
sumed. 

Yet  the  following  observations  of  Albarran  are  noteworthy: 

"If  instead  of  comparing  the  total  quantity  of  urine  excreted  during  a  cer- 
tain time,  we  compare  the  urine  in  a  series  of  fractions  of  this  time,  we  shall 
be  studying  the  actual  functional  activity  (marche  fonctionelle)  of  the  two  kid- 
neys. If,  for  example,  instead  of  collecting  the  urines  for  three  hours,  and  com- 
paring the  total  excretion  of  the  two  kidneys  during  that  period,  we  divide  these 
three  hours  into  six  half -hour  periods,  and  thus  compare  six  specimens  from  each 
kidney,  we  can  plot  out  a  curve  for  the  -diseased  kidney  and  another  curve  for 
the  healthy  kidney.  By  comparing  the  progress  of  elimination  from  each  kidney, 
as  shown  in  these  curves,  we  acquire  some  very  important  data  since  we  know 
that  the  curve  of  excretion  in  a  kidney  is  flattened  in  proportion  to  the  disease  of 
that  kidney." 

Such  prolonged  observations  are  not  necessary.  But  just  as  the 
routine  urinalysis  of  ureter  catheter  specimens  may  be  certified  to  by 
the  phenolsulphonephthalein  output,  so  the  variations  in  the  kidney 
function,  as  measured  over  periods  as  short  as  15  minutes  each,  may  be 
taken  into  consideration  in  estimating  the  functional  capacity  of  a 
kidney. 

We  make  this  comparison  tacitly,  at  least,  every  time  a  phenol- 
sulphonephthalein test  is  made  without  ureter  catheterization.  For  in 
measuring  the  excretions  for  the  first  and  second  hour  separately  (as 
should  always  be  done)  we  note  not  only  that  a  high  excretion  in  the 
first  hour  is  likely  to  be  followed  by  a  very  low  one  in  the  second, 
but  that  lowering  of  the  first  hour  excretion  heightens  that  in  the 
second  hour  only  up  to  a  certain  point.  Thus  if  the  first  hour  excre- 
tion falls  as  low  as  from  10  to  25  per  cent,  the  excretion  in  the  second 
hour  is  likely  to  fall  within  the  same  figures.  But  if  the  first  hour 
excretion  falls  below  10  per  cent,  that  in  the  second  hour  does  not 
correspondingly  increase.  On  the  contrary,  it  tends  to  fall  in  precisely 
the  same  ratio  as  that  of  the  first  hour  so  that  the  differences  in  excre- 
tion hour  by  hour  when  the  first  hour's  excretion  is  below  10  per  cent 
is  very  slight  indeed.  In  other  words,  the  grave  impairment  of  the 
kidney  function  shows  itself  not  only  by  reducing  the  initial  output  of 
phenolsulphonephthalein,  but  by  keeping  that  output  very  close  to  the 
same  level  until  all  the  dye  is  excreted. 

The  same  observation  may  be  made  in  reference  to  urea  output. 
The  gravely  impaired  kidneys  of  prostatics,  for  instance,  excrete  about 
the  same  percentage  of  urea  day  in  and  day  out,  year  in  and  year  out. 
The  kidneys  are  all  the  while  working  at  top  speed.  If  an  extra  strain 
is  put  upon  them,  as  exemplified  by  the  injection  of  phenolsulphone- 


RENAL  FUNCTION  TEST  WITH  THE  URETER  CATHETER   85 

phthalein,  they  cannot  handle  tlie  business  at  hand  promptly,  but  must 
divide  it  np  and  gTadually  dispose  of  it. 

Since  surgical  kidney  diseases  usually  destroy  the  tubular  epithe- 
lium rather  than  the  glomeruli  considerable,  nay  very  marked,  variation 
in  water  excretion  may  be  observed  from  kidneys  that  show  every 
other  evidence  of  a  gravely  impaired  function. 

Thus  the  lowered  ability  to  excrete  solids,  and  the  lack  of  flexibility 
in  the  kidney  function  are  but  different  phases  of  the  same  physiological 
phenomenon.  Each  is  of  assistance  in  estimating  impairment  of  the 
kidney  function. 


TECHNIC  OF  RENAL  FUNCTION  TEST  WITH  THE  URETER 

CATHETER 

The  routine  I  prefer  is  the  following: 

If  there  is  question  of  hemorrhage  from  the  kidney,  no  instrument 
is  passed  into  the  ureter  until  the  precise  nature  of  each  urinary  jet 
has  been  carefully  studied.  If  the  wax-tipped  catheter  is  to  be  em- 
ployed, this  is  passed  before  the  ureters  are  catheterized.  If  any  diffi- 
culty in  finding  the  ureter  mouth  is  anticipated  inject  5  c.c.  of  a  satu- 
rated (0.6  per  cent)  solution  of  indigocarmin,  and  do  not  introduce 
the  cystoscope  until  this  appears  in  the  urine.  Finally  the  ureter 
catheters  are  introduced,  and  the  cystoscope  is  held  in  place  until  one 
is  certain  that  the  catheters  are  working  well.  The  first  20  to  30 
drops  are  permitted  to  escape  in  order  to  assure  uncontaminated  urine. 
Then  with  the  cystoscope  still  in  place  at  least  0.5  c.c.  of  urine  is  col- 
lected from  each  kidney  for  microscopic  examination,  the  character  of 
the  jet  being  meanwhile  noted  as  evidence  of  pelvic  or  ureteral  dilata- 
tion. The  specimens  thus  obtained  are  then  set  aside,  the  cystoscope 
withdrawn,  1  c.c.  of  phenolsulphonephthalein  solution  injected  into  a 
vein,  and  a  second  set  of  specimens  meanwhile  collected  for  urea 
estimation  by  the  h}^pobromid  method.  From  time  to  time,  after  a 
lapse  of  two  minutes,  a  drop  of  urine  from  each  catheter  is  per- 
mitted to  fall  into  a  white  pus  basin  containing  a  few  drops  of  sodium 
hydrate  solution  until  the  red  color  appears  in  the  urine.  The  ureter 
catheters  are  then  transferred  to  a  third  set  of  specimen  bottles,  care 
being  taken  to  note  the  time  of  appearance  of  the  dye  in  the  urine  of 
each  kidney,  and  an  effort  being  made  to  estimate  whether  undue 
delay  in  one  side  is  caused  by  inefficient  action  of  the  catheter,  or  of 
the  kidney.  In  deciding  this  point,  the  concentration  of  dye  in  the 
urine  is  a  most'  important  factor.  For  if  there  is  delayed  output  on 
account  of  kidney  inefficiency  the  concentration  of  the  dye  is  sure  to 
be  low.    Wliile  if  the  delay  is  due  to  catheter  inefficiency,  when  the  dye 


86  ESTIMATION  OF  THE  RENAL  FUNCTION 

does  appear  it  is  in  considerable  concentration.  Specimens  for  phenol- 
sulphonephtlialein  estimation  are  then  collected  for  10  or  15  minutes, 
depending  upon  whether  the  findings  seem  likely  to  prove  obvious  or 
doubtful,  rinallj  a  fourth  pair  of  specimens  may  be  collected  for 
bacteriological  examination  if  this  is  to  be  made  by  culture.-^ 

*  The  order  of  procedure  above  described  is  the  one  calculated  to  give  the  best 
results.  The  first  specimen  obtained  should  be  used  for  microscopical  analysis  because 
it  is  likely  to  contain  less  ureteral  epithelium  and  blood  than  any  of  the  subsequent 
specimens.  On  the  other  hand,  this  first  specimen  may  be  contaminated  with  pus 
from  the  bladder.  If  there  is  any  question  of  this,  a  microscopical  examination 
of  specimen  No.  2  should  be  made.  Specimen  No.  2  is  essentially  for  urea  estima- 
tion. This  may  be  compared  with  Nos.  1  and  4,  after  these  have  been  centrifuged, 
thereby  getting  a  series  of  observations  that  may  be  of  advantage  in  estimating 
changes  in  the  kidney  flexibility. 

Conclusions  derived  from  this  series  must,  however,  be  taken  with  a  grain  of 
salt  for  the  first  specimen  is  very  likely  not  only  to  be  contaminated  by  the  urine 
from  the  bladder,  but  also  to  show  the  effect  of  reflex  inhibition  due  to  cysto- 
scopy. Finally  the  reason  for  taking  the  specimens  for  culture  last  is,  not  only 
that  these  are  the  least  likely  to  be  contaminated  from  the  bladder,  but  also 
because  any  antiseptics  in  the  ureter  catheter  are  most  likely  to  have  been  washed 
away. 

My  catheters  are  so  strongly  formalized  that  I  find  it  necessary  to  delay  the 
culture  specimens  to  the  last,  and  also  to  drop  them  immediately  into  culture  tubes; 
otherwise  the  formalin  kills  the  bacteria  before  they  can  be  transferred  to  the  lab- 
oratory. 


CHAPTEE    IX 
RADIOGRAPHY 

It  is  not  my  province  to  instruct  the  radiologist  how  to  obtain 
good  pictures  of  the  urinary  tract.  This  can  be  learned  only  by  long 
experience.  Some  radiologists  obtain  good  pictures  but  interpret  them 
rashly  and  inaccurately.  Others  get  faint  pictures,  but  interpret  them 
with  extraordinary  skill.  The  radiologist  who  can  be  depended  upon 
to  obtain  good  pictures,  and  to  interpret  them  with  discretion,  is  as 
rare  a  treasure  as  the  good  diagnostician  in  any  other  branch  of 
medicine. 

Obedience  to  the  following  rules  is  essential  to  success : 

1.  The  best  pictures  are  obtained  in  the  morning  after  the  patient 
has  taken  an  ounce  of  castor  oil  the  night  before,  and  a  low  saline  or 
soapsuds  enema  immediately  before  the  picture  is  taken. 

2.  The  whole  urinary  tract  should  be  covered  no  matter  what  the 
preliminary  diagnosis.  Better  results  are  obtained  by  using  three  to 
five  small  plates,  rather  than  one  large  one.  The  urinary  tract  extends 
from  the  tenth  rib  above  to  the  pubes  below. 

3.  A  good  picture  of  the  abdominal  portion  of  the  urinary  tract 
should  plainly  show  the  tips  of  the  ribs  and  of  the  transverse  processes, 
and  the  border  of  the  psoas  muscle.  If  the  diameter  of  the  patient 
is  no  more  than  twelve  inches,  or  if  he  is  not  so  lean  as  to  be  bereft  of 
perirenal  fat,  such  a  picture  should  at  least  suggest  the  outlines  of  the 
kidney. 

4.'  A  good  picture  of  the  bony  pelvis  should  plainly  show  the  tip 
of  the  coccyx,  and  of  the  iliac  spines.  The  tube  should  be  placed  so 
high  as  to  bring  the  prostate  within  the  field  of  vision  above  the 
pubic  bone. 

5.  All  plates  should  be  taken  in  duplicate,  and  stereoscopically. 


PROSTATIC  CALCULI 

Prostatic  calculi  always  contain  a  large  percentage  of  lime,  and 
apparently  always  show  in  the  x-ray  plate  (PI.  III).  They  appear 
as  a  group  of  dots  occupying  the  regions  of  the  lateral  lobes  of  the  Dros- 
tate.    The  larger  prostatic  stones  may  reach  such  an  extraordinary  size 

87 


RADIOGRAPHY 


as  to  be  mistaken  for  vesical  calculi.  I  have  several  times  known  pros- 
tatic and  vesical  calculi  to  co-exist.  In  some  instances  the  vesical  cal- 
culus is  shown  by  the  x-ray  (Fig.  27),  in  others  not.  The  differential 
diagnosis  is  made  by  cystoscopy. 


VESICAL  CALCULI 

In  the  diagnosis  of  bladder  stone  the  cystoscope  stands  first,  the 
searcher  second,  the  x-ray  third,  in  point  of  accuracy.     Stones  originat- 


FiG.  27. — Radiogram  Showing  Bladder  and  Prostatic  Calculi. 

ing  in  the  bladder  are  so  often  bereft  of  lime  salts  as  to  show  very  badly 
in  the  x-fay.  It  is  to  be  noted  that  small  stones  often  lie  to  one  side 
of  the  median  line,  and  sometimes  even  give  the  impression  of  being 
in  the  ureter  (Figs.  29  and  30). 

Stones  in  the  bladder,  otherwise  invisible,  may  be  shown  in  the 


PLATE    III 


d    "  .2 


a     &: 


03     o 


&^      cc     -T3 


a    a    3 

O      M     3" 
ii       r^       OJ 


O  "^ 


FiQ.  28. — Vesical  Calculus;  Phlebolith  in  Region  of  Pelvic  Ueeteb 


Fig.  29. — Vesical  Calculi. 
89 


90  RADIOGRAPHY 

x-ray  after  mjecting  air  into  the  viscus,  or  sometimes  after  coating  them 
with  collargol.  These  devices,  however,  are  scarcely  worth  resorting  to 
since  cystoscopy  shows  the  stone,  and  many  other  things  besides. 


URETER  CALCULI 

The  characteristics  of  ureteral  stone  as  revealed  by  radiography  are 
the  following: 

They  are  never  spherical;  they  are  usually  oblong;  in  consistency 
they  are  not  irregular  and  motheaten;  they  may  be  found  in  any  por- 
tion of  the  ureter,  but  are  most  common  near  its  two  extremities. 

The  presence  of  stone  in  the  ureter  may  not  be  disclosed  by  the 
x-ray,  either  because  the  shadow  of  the  stone  is  overlaid  by  that  of 
bone,  feces,  or  other  solid  matter  or — we  know  not  why.  Cabot  has 
called  attention  to  the  frequency  with  which  stones  are  overlooked  in 
the  region  of  the  sacro-iliac  synchondrosis  and  has  shown  that  by  arch- 
ing the  patient's  back  over  a  pillow  and  taking  the  picture  at  the 
extreme  of  obliquity  with  the  tube  over  the  patient's  chest,  and  the  plate 
under  the  buttocks,  the  ureters  may  be  drawn  clear  of  the  shadow  of  the 
pelvis,  and  stones,  otherwise  invisible,  may  be  seen.  An  unusually  good 
x-ray  will,  however,  show  a  stone  even  through  the  pelvic  bones. 

The  second  reason  for  invisibility  is  no  reason.  I  have  known 
the  same  radiographer  overlook  a  stone  in  the  lower  ureter  in  several 
plates,  and  a  few  weeks  later  to  show  it  very  plainly.  The  stone  was 
composed  almost  exclusively  of  oxalate  of  lime. 

Differential  Diagnosis  of  Stone  in  the  Ureter. — The  stereoscope  is 
of  great  assistance  in  differentiating  ureteral  stone  from  other  objects 
likely  to  be  mistaken  for  this.  The  course  of  the  ureters  is  shown  in 
Fig.  30.  In  their  abdominal  portions  they  begin  one  or  two  centi- 
meters to  the  outer  side  of  the  second  lumbar  transverse  process  or 
thereabouts,  and  if  normal,  fall  almost  vertically  to  the  brim  of  the 
pelvis  where  they  appear  to  curve  outward  slightly,  and  then  sweep 
inward  well  to  the  inner  side  of  the  spine  of  ischium. 

An  oblong  shadow  in  the  course  of  the  ureter  is  likely  to  be  a  ure- 
teral stone.  But  such  a  shadow  is  no  more  sufficient  evidence  of  the 
presence  of  stone  than  the  absence  of  such  a  shadow  is  evidence  of  its 
absence.  The  diagnosis  of  stone  must  he  confirmed  by  other  physical 
evidence,  notably  by  the  wax-tipped  catheter,  pyelography,  or  evidence 
of  renal  infection  and  deficient  function  (PI.  IV).  Ureteral  stone 
must  be  differentiated  from  the  following: 

Phlebolith,  or  calculus  in  the  seminal  vesicle. 

Tubercular  glands. 

Enteroliths  and  foreign  substances  in  the  intestines. 


PLATE    IV 


Fig.  1 


Fig.  2 


Fig.  1. — Shows  an  oxalate  stone  in  the  lower  ureter. 

Fig.  2. — Shows  the  same  stone  surrounded  by  coUargol  (in  the  dilated  ureter  about  and  above 
it)  injected  through  the  ureter  catheter. 


Fig.  30.— The  Stone-bearing  Area.  Over  the  pubes  is  the  ■^mall  oval  area  o  prostatic 
calculi.  From  this  the  usual  area  for  phleboliths  runs  along  tne  edge  of  the  pelvis  (round 
dots).  Bladder  stones  lie  in  the  large  black  ovaL  high  in  the  pelvis.  The  usual  course 
of  the  ureters  is  shown  in  black. 


91 


92  RADIOGRAPHY 

Phlebolitlis  (Figs.  28,  31)  may  be  readily  distinguished  by  being 
round  and  not  oblong,  and  lying  near  the  spine  of  the  ischium,  or 
below  it,  rather  than  above  and  to  the  inner  side  of  it.  In  doubtful 
cases  the  diagnosis  may  be  thus  made  by  repeating  the  x-ray  with  the 


Fig.  31. — Phleboliths.    The  ureters  are  identified  by  visible  catheters. 

visible  catheter  in  place,  or  by  pyelography  or  the  wax-tipped  catheter. 

ISTot  so  very  infrequently  a  sclerotic  artery  may  be  seen  in  the 
region  of  the  pelvic  ureter,  either  as  a  ring  (PI.  Ill)  or  a  narrow 
ribbon  suggesting  a  slightly  dilated  ureter. 

Tubercular  glands  may  well  be  oblong,  though  they  are  likely  to 
be  rather  rounded  or  irregular  in  shape  and  often  very  motheaten  in 
consistency  (PL  IV).  In  doubtful  cases  the  diagnosis  is  made  as  in 
the  case  of  phleboliths. 

RENAL  CALCULI 

rigs.  33,  34  and  35  illustrate  the  situation,  and  various  types  of 
renal  stone.  It  will  be  noted  that  in  order  to  include  all  stones  the 
photograph  must  at  least  cover  the  eleventh  rib,  and  preferably  the 


PLATE    V 


Pyelography  in  the  Diagnosis  of  Ureteral  Calculus. 

The  patient  had  an  ancient  urethral  stricture  and  suffered  from  vaRue  lumbar  pain,  while 
the  urine  showed  mild  pyelonephritis  (pus,  bacteria,  albumin,  and  casts).  Radiography 
showed  what  appeared  to  be  a  stone  in  the  upper  part  of  the  loft  ureter  and  the  functional 
tests  revealed  deficient  function  of  the  left  kidney.  Both  pelves  were  accordingly  in- 
jected with  argyrol  and  a  radiograph  obtained,  which  showed  both  pelves  undilated,  the  right 
ureter  (left  in  plate)  dropping  normally  in  a  straight  line,  while  the  left  (right  in  plate) 
curved  outward,  evidently  adherent  to  the  lower  pole  of  the  kidnej%  leaving  the  shadow  of  the 
supposed  stone  between  it  and  the  spine.  The  pyelonephritis  and  the  slight  functional  inac- 
tivity of  the  left  kidney  (due  to  ureteral  adhesions)  were  thus  shown  to  be  due  to  infection 
from  the  urethral  retention  and  not  to  stone. 


THE  VISIBLE  CATHETER  AND  PYELOGRAPHY  93 

tenth  interspace.  If  stone  is  suspected,  but  not  shown  by  x-ray,  it 
may  be  disclosed  by  pyelography.  This  may  identify  the  situation  of 
the  stone  by  showing  a  dilated  calyx  or  pelvis.  If  the  patient  is  again 
radiographed  a  few  hours  later,  it  is  sometimes  possible  to  see  the  stone 
coated  with  the  silver  salts  which  remain  in  the  kidney  pelvis. 


f^y^j^si^.^^^.'t'n-!  ■  ..:.^abL!s^;^^^^^r.,..mm,.^sm;^i 


Fig.  32. — Calculus  in  Seminal  Vesicle.     It  is  identified  by  the  finger  in  the  rectum. 

Gall-stones  can  usually  be  distingTiished  as  round  bodies,  lighter  in 
center  than  circumference,  and  situated  nearer  the  anterior  than  the 
posterior  abdominal  wall  (PI.  VII). 


THE  VISIBLE  CATHETER  AND  PYELOGRAPHY 

The  visible  catheter  is  employed  to  identify  the  position  of  stone 
or  suspected  shadows  in  the  ureter  and  kidney  pelvis.  At  present 
two  implements  are  employed,  the  one  a  catheter,  the  other  a  bougie, 
each  heavily  coated  with  bismuth  paint.  This  metallic  paint  renders 
the  catheter  or  bougie  visible  to  the  x-ray.     Therefore  its  introduction 


94 


RADIOGRAPHY 


into  the  ureter  identifies  its  position  in  relation  to  any  suspected  stone 
(Fig.  31). 

Bugbee  has  shown  that  if  the  visible  bougie  is  heated  it  becomes 
extremely  flexible,  and  can  be  employed,  not  only  to  identify  the  posi- 
tion of  the  ureter,  but  also  to  curl  up  in  the  kidney  pelvis,  and  show- 
its  shape  and  position. 

But  we  may  go  further  than  this,  and  inject  into  the  ureter  and 


Fig.  33. — Numerous  Small  Oxalate  Calculi  in  Loweb  Calyces  of  Right  Kidney. 


kidney  pelvis  a  solution  or  suspension  of  some  metallic  salt  visible  to 
the  x-ray,  thus  to  exhibit  misplacement  and  deformities  of  this  portion 
of  the  urinary  channel.  This  is  pyelography  (PI.  IV,  also  Figs.  36 
and  37). 

Pyelography  may  be  performed  with  a  number  of  different  solu- 
tions. The  chief  requisite  is  that  the  solution  shall  throw  a  good 
x-ray  shadow,  and  yet  be  fluid  enough  to  pass  in  through  the  ureter 
catheter,  and  out  through  the  ureter.  I  have  frequently  employed 
argyrol  in  30  to  50  per  cent  solution,  but  the  margin  between  a  solu- 
tion of  argyrol  so  thick  as  to  be  muddy  and  so  thin  that  it  casts  a  very 


PLATE    VI 


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96  RADIOGRAPHY 

poor  shadow,  is  too  narrow.  Bismuth  emulsions  are  likewise  too  thick. 
Collargol  in  5  to  10  per  cent  solution  gives  excellent  pictures  but 
among  the  deaths  that  have  followed  its  injection  some  at  least  seem 
referable  to  poisoning  from  the  collargol  absorbed  through  the  lym- 
phatics and  blood  vessels  of  the  kidney..  Two  among  the  many  sub- 
stitutes suggested  have  proven  equally  serviceable  in  my  hands,  viz. : 


Fig.  36. — Normal  Kidney  Pelvis. 

1.  Argentide  emulsion,  prepared  as  follows  (E.  L.  Young  ^ ) : 
Quince  seed  100  grains,  water  8  ounces;  macei-ate  for  24  hours  with  fre- 
quent agitation;  do. not  crush  the  seed;  strain  through  cloth.  Add  2  per  cent 
boric  acid  up  to  20  ounces.  It  is  important  to  extract  with  water  and  not 
with  the  boric  acid  solution.  Enough  of  this  mucilage  is  added  to  12.5  c.c.  of 
argentide  to  make  50  c.c.  and  the  mixture  is  vigorously  shaken  for  two  minutes — 
the  shaking  is  an  essential  part  of  the  process.  The  value  of  this  substance 
depends  on  the  mode  of  preparation.     It  keeps  for  several  weeks. 

This  emulsion  is  irritating  to  the  bladder  but  not  to  the  kidney  pelvis. 

2.  Ten  per  cent  solution  of  thorium  nitrate  (Burns  ^). 

"^  Boston  Med.  and  Surg.  Jour.,  1915,  clxxii,  539. 
"Jour.  A.  M.  A.,  1915,  Ixiv,  2126. 


PLATE    VTI 


G all-Stones  (Courtesy  of  Dr.  Cole). 


THE  VISIBLE  CATHETER  AND  PYELOGRAPHY 


97 


Dangers  of  Pyelography. — Pyelography  is  a  dangerous  procedure. 
A  number  of  deaths  have  been  reported  as  resulting  from  it  ^  and  many 
more  are  unreported.      Pyelography  may  injure  the  kidney   in  two 


ways: 


1.  At  the  moment  of  injection  it  may  be  driven  into  the  kidney 


Fig.  37. — Normal  Kidney  Pelvis.     Note  visible  catheter  extending  to  upper  calyx. 


parenchyma,  either  by  the  force  of  the  injection  itself,  or  by  the  reaction 
of  the  kidney  colic  excited  by  the  injection.  The  fluid  is  driven  into 
the  lymphatic  and  blood  vessels  about  the  kidney  pelvis,  thence  it 
radiates  through  the  kidney  itself,  making  cone-shaped  ''infarcts"  char- 
acterized by  acute  inflammation  and  degeneration. 

Thence  the  collargol  is  carried  into  the  general  circulation,  and 
excreted,  both  by  the  glomeruli  of  the  injured  kidney  and  that  of  its 
fellow. 

Thus  in  the  injured  kidney,  collargol  may  be  found  in  the  tubules 
and  glomei-uli,  but  only  if  the  lesion  has  existed  for  a  sufiicient  length 
of  time  to  pennit  excretion  to  begin  (Fig.  38). 

^Keyes  and  Mohan.     Amcr.  Jour,  of  Med.  Sciences,  191.5,  cxlix,  30. 


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PLATE    Viii 


Fig.  2 
Visible  Catheter  Points  Directly  Toward  the  Shadow. 

Fig.  1. — Patient  complained  of  pain  in  the  hip.  X-ray  showed  a  suspicious  shadow  on 
tip  of  transverse  process  of  fourth  luml)ar  vertebra.  Ureter  catheter  always  stopped  at 
15  cm.     Wax  not  scratched.     Renal  function  perfect-     Diagnosis:  no  stone. 

Fig.  2. — ^Confirmed  by  injection  of  coUargol,  which  showed  a  kinked  ureter,  remote  from  the 
suspected  shadow. 


CYSTOGRAPHY  99 

2.  Secondary,  or  late  infiltration,  may  occur  even  without  the 
slightest  pain  at  the  time  of  injection  as  a  result  of  obstruction  of  the 
strictured  or  kinked  ureter.  On  account  of  these  dangers,  the  follow- 
ing rules  of  technic  are  absolute. 

Technic. — 1.  PyelogTaphy  should  never  be  performed  excepting 
upon  a  patient  in  a  hospital  so  that  if  acute  renal  retention  follows  the 
operation,  the  kidney  may  immediately  be  drained  (Fig.  39). 

2.  In  order  to  minimize  the  danger  of  renal  retention,  the  patient 
should  lie  upon  his  back  for  at  least  twelve  hours  after  the  operation. 

3.  Advanced  renal  retention  gives  the  most  beautiful  pictures  to 
pyelography,  but  this  condition  can  be  diagnosed  very  accurately  with- 
out pyelography  and  it  is  in  this  class  of  cases  that  the  operation  is 
most  dangerous. 

4.  Pyelography  is  relatively  safe  and  eminently  useful  in  the  diag- 
nosis of  tumor,  stone,  small  hydronephrosis,  and  sometimes  in  tuber- 
culosis. 

5.  The  injection  should  always  be  made  by  gravity  with  the  con- 
tainer not  more  than  two  or  three  feet  above  the  level  of  the  patient's 
body. 

G.  The  capacity  of  the  normal  kidney  pelvis  may  be  as  little  as  2  or 
3  cc,  but  usually  5  c.c.  may  be  injected  with  impunity.  It  is  wiser 
never  to  inject  more  than  10  c.c.  Leaving  the  catheter  in  to  drain  off 
the  fluid  is  scarcely  worth  while  unless  there  is  ureteral  retention. 


CYSTOGRAPHY 

The  devices  for  making  bladder  lesions  visible  to  the  x-ray  are  much 
more  numerous  than  those  suggested  for  a  similar  purpose  in  the  kidney 
pelvis.  Thus  Kelly  has  been  able  to  demonstrate  the  size  of  bladder 
tumors  by  coating  them  with  a  visible  fluid,  and  then  filling  the  bladder 
with  air.  The  size  of  a  saccule  may  be  roughly  shown  by  a  small  ureter 
bougie  coiled  up  within  it. 

Bladder  lesions,  especially  saccules,  usually  show  best  if  the  bladder 
is  not  fully  distended  (usually  100  c.c).  Argentide  should  not  be 
used  in  the  bladder ;  it  is  much  too  irritating.  Five  per  cent  collargol, 
or  15  per  cent  argyrol,  gives  excellent  pictures.  Thorium  is  perhaps 
the  most  satisfactory.  The  usual  stereoscopic  pictures  exhibit  sac- 
cules much  better  than  pictures  taken  with  the  tube  iu  the  median  line 
(Figs.  114,  115;  PL  XVIII). 


CHAPTEE   X 
GONOERHEA:  ITS  SOCIAL  ASPECTS  AND  PREVENTION 

Gois'OEEHEA  is  EH  aciite  infectious  disease  caused  by  the  gonococcus. 
Its  usual  manifestation  is  a  local  inflammation  of  the  infected  surface. 
This  inflammation  is  characterized  primarily  by  redness,  swelling,  and 
exudation  of  pus.  It  extends  by  direct  continuity  and  rarely  by  en- 
trance of  the  gonococcus  into  the  circulation.  Thus  gonorrhea  is  usually 
a  local  inflammation,  rarely  a  general  infection. 

The  usual  portal  of  infection  in  the  male  is  the  urethra,  in  the 
female  the  vulva  or  the  urethra.  The  disease  is  usually  transmitted  by 
sexual  intercourse.  Indirect  transmission  to  adults  by  means  of  cloth- 
ing, etc.,  infected  with  gonorrheal  pus  is  extremely  rare,  both  because 
of  the  relative  immunity  to  gonorrhea  of  the  skin  and  the  mouth,  the 
only  surfaces  with  which  such  articles  are  likely  to  come  in  contact, 
and  also  because  the  coccus  perishes  as  soon  as  the  secretion  containing 
it  dries. 

Infants  and  young  children  are  infinitely  more  susceptible  than 
adults  to  gonorrhea.  Indirect  transmission  of  the  disease  is  a  frequent 
cause  of  gonorrheal  vulvovaginitis  in  little  girls.  I  have  seen  but  one 
instance  of  indirect  transmission  in  the  adult  male. 

The  only  other  part  of  the  body  likely  to  be  infected  with  gonorrhea 
is  the  ocular  conjunctiva.  The  well-known  frequency  of  gonorrheal  con- 
junctivitis neonatorum  is  evidence  of  this  susceptibility  in  infants,  but 
the  relative  infrequency  of  gonorrheal  conjunctivitis  in  later  life  is  best 
explained  by  the  theory  that  the  conjunctiva  of  the  adult  has  lost  its 
excessive  sensitiveness  to  the  gonococcus.  How  else  explain  the  fact 
that  among  the  innumerable  filthy  gonorrheics  who  throng  our  venereal 
climes  conjunctivitis  is  almost  an  unknown  complication?  It  is  not 
conceivable  that  their  immunity  is  due  either  to  the  cleanliness  of  their 
hands  or  to  the  fact  that  these  dirty  hands  keep  away  from  their  eyes. 
That  an  adult  eye  is  occasionally  inoculated  only  increases  our  wonder 
that  more  are  not. 

Genitals  and  eyes  apart,  the  human  integ-umcnt  is  almost  immune 
to  gonorrhea.  The  rectum  may  be  inoculated  by  sodomy  or,  in  the 
female,  by  drippings  from  the  inflamed  vulva.  A  very  few  instances 
attest  the  fact  that  the  skin  and  the  buccal  and  nasal  mucous  membranes 
may  be  inoculated. 

100 


PREVALENCE  OF  GONORRHEA  101 

The  importance  of  gonorrhea  to  the  community  rests  chiefly  upon 
four  factors:  first,  its  transmissibility  by  sexual  intercourse;  second, 
its  rebelliousness  to  treatment,  its  capacity  to  extend  to  the  uttennost 
parts  of  the  urinary  and  genital  mucous  membranes  and  its  involvement, 
no  less  terrible  for  being  rare,  of  the  whole  economy  in  gonococcus  sep- 
ticemia ;  third,  its  chronicity  and  latency,  which  deceive  the  patient  and 
even  his  physician  into  the  belief  that  the  disease  is  cured  until  a  new 
outbreak  in  the  patient  himself,  or  infection  of  a  sexual  partner,  or,  if 
the  patient  be  a  parturient  woman,  of  the  eyes  of  her  child,  reveals  the 
inveteracy  and  virulence  of  the  disease;  fourth,  the  ease  with  which 
female  children  are  indirectly  contaminated,  and  the  hospital  and 
family  epidemics  resulting  therefrom. 

PREVALENCE  OF  GONORRHEA 

Prevalence  in  the  Army — The  prevalence  of  gonorrhea  in  the  army 
of  the  United  States  is  a  rough  measure  of  its  prevalence  in  cities  among 
young  adult  males.  Age,  temptation,  and  protection  are  approximately 
the  same  in  each  case. 

The  figures  given  in  the  Surgeon  General's  Report  for  1908  are: 

Mean  enlisted  strength  of  the  army — 53,803  men. 

I^umber  of  cases  of  gonorrhea  treated  during  the  year  1907 — 5,782 
(of  whom  1,942  were  in  the  Philippines). 

Days  sick— 134,795. 

Discharged  as  unfit  for  duty — 58. 

Died— 1. 

This  means  that  during  the  year  1907  more  than  12  per  cent  of  the 
army  had  gonorrhea  (in  the  United  States  10.768  per  cent,  in  the  Phil- 
ippines 18.-719  per  cent).  The  average  duration  of  the  disease  was 
about  twenty-three  days.^ 

One  per  cent  of  the  men  diseased  were  discharged  as  unfit  for  duty. 

Let  us  compare  gonorrhea  with  other  diseases.  In  prevalence  it 
stands  easily  first,  with  malaria  (6.319  per  cent)  second,  enteritis  and 
diarrhea  (4.926  per  cent),  bronchitis  (4.743  per  cent),  and  influenza 
(4.046  per  cent)  following.  In  noneffectiveness  (number  of  days  sick) 
gonorrhea  is  again  first  (36.93  per  cent),  followed  by  the  other  venereal 
diseases,  syphilis  (15.367  per  cent),  and  chancroid  (14.567  per  cent), 
and  with  tuberculosis  (14.271  per  cent)  fourth.  As  a  cause  for  dis- 
charge from  the  army,  however,^  gonorrhea  (58)  stands  fourth  to  tuber- 

^  Many  a  case  of  chronic  urethritis  is  not  called  to  the  attention  of  the  medical 
officer.  From  infection  to  positive  cure  in  civil  life,  the  average  duration  is  about 
fifty  days. 

^The  detail  given  is  "chronic  gonorrhea,"  21;  epididymitis,  3;  ophthalmia,  8; 
rheumatism,  20;    stricture,  2;   other  results,  3. 


102       GONORRHEA:  ITS  SOCIAL  ASPECTS  AND  PREVENTION 

culosis  (177),  syphilis  (94),  and  insanity  (79).  As  a  cause  of  death  it 
is  insignificant;  only  5  deaths  due  to  gonorrhea  are  recorded  in  the 
Surgeon  General's  Reports  for  the  last  decade. 

From  these  figures  it  is  evident  that  the  immediate  results  a  young 
man  may  expect  from  a  well-treated  gonorrhea  are  an  acute  sickness 
lasting  a  month  or  so,  with  about  one  chance  in  a  hundred  of  grave  or 
permanent  impairment  of  function,  and  practically  no  prospect  of 
death. 

But  these  figures  do  not  show  the  chronic  gonorrhea,  the  sterility, 
the  prolonged  infectiousness  that  are  the  really  important  elements  in 
the  prognosis  of  chronic  gonorrhea  in  the  male. 

Prevalence  in  Civil  Life. — The  prevalence  of  prostitution  and 
sexual  promiscuity  in  our  cities  makes  gonorrhea  endemic  among  their 
population;  smaller  towns  suffer  in  proportion  to  the  laxity  of  their 
morals  and  their  proximity  to  urban  centers,  while  the  countryside 
is  subjected  to  epidemics  of  the  disease  by  the  return  of  the  Prodigal 
Son. 

In  1901,  the  ''Committee  of  Seven"  ^  reported  that  there  were  ap- 
parently 162,372  patients  suffering  from  venereal  disease  in  l^ew  York 
City,  and  of  these  nearly  90  per  cent  were  gonorrheics.  There  were 
15,969  cases  of  gonorrhea  actually  reported,  of  which  1,941  were  in 
women  and  488  in  children.  Of  these  children,  265  had  purulent 
ophthalmia,  218  vulvovaginitis,  5  urethritis. 

Morrow  estimates  ^  that  60  per  cent,  Forscheimer  ^  that  51  per  cent 
of  the  adult  male  population  of  the  United  States  have  had  gonorrhea. 
He  adds:  "Twenty  per  cent  of  these  young  men  will  become  infect- 
ed before  they  are  twenty-one,  over  60  per  cent  before  their  twenty- 
fifth  year,  and  more  than  80  per  cent  before  they  pass  their  thirtieth 
year." 

Among  women  gonorrhea,  though  more  severe,  is  less  common  than 
among  men.  In  the  statistics  given  above  the  proportion  of  men  to 
women  is  16  to  1.  It  is  shocking  to  learn  that  almost  one-third  of  the 
reported  cases  of  gonorrhea  occurred  in  married  women,  to  whom  the 
infection  had  been  conveyed  by  their  husbands.  Xine  hundred  and 
eighty-eight  cases  of  marital  infection  were  reported,  and  the  unre- 
ported cases  were  believed  to  be  six  times  as  numerous. 

Add  to  this  the  ghastly  array  of  488  children  with  ocular  and  gen- 

^  Medical  Ne^vs,  December  21,  1909. 

^"Social  Diseases  and  Marriage."  Also  Trans.  Am.  Soc.  Sanitary  and  Moral 
Prophylaxis,  1906,  1,  18. 

'  Boston  Med.  and  Surg.  Jour.,  Aug.  6,  1908.  The  statistics  of  gonorrhea  in 
Germany  and  Austria  are  given  by  Erb  (Munich,  med.  Wocliensclir.,  1906,  liii,  p. 
2329,  and  1907,  No.  31)  and  Blaschko  (Zeitschr.  f.  BeMmpfung  d.  Geschlectsk.,  1907, 
vj,  No.  1).     Erb's  contentions  are  approved  in  Jour.  A.  M.  A.,  1907,  xlix,  44. 


DURATION  OF  THE  DISEASE  103 

ital  ^  gonorrhea.      Truly  the  much-heralded  syphilis  insontium  pales 
before  gonorrhea  insontium! 


DURATION  OF  THE  DISEASE 

"A  gonorrhea  begins  and  God  alone  knows  when  it  will  end/'  said 
Ricord  more  than  a  generation  since;  and  the  aphorism  is  as  true  to- 
day as  the  day  it  was  uttered.  Where  there  are  no  glands  (e.  g.,  in  the 
conjunctiva)  gonorrhea  runs  an  acute  course  and  then  disappears;  but 
in  the  genital  passages  it  shows  a  marked  tendency  to  become  chronic  by 
causing  chronic  glandular  catarrh  and  periglandular  sclerosis. 

From  the  male  urethra  the  gonococci  usually  disappear  within  six 
months.  Persistence  of  gonococci  for  more  than  eighteen  months  in 
the  male  urethra  is  exceptional.  The  catarrh  may  continue  longer  than 
this,  but  it  is  kept  alight  by  the  associated  microorganisms  that  persist 
after  the  gonococcus  has  disappeared. 

The  exceptional  case  whose  gonococci  remain  alive  and  at  least  po- 
tentially virulent  for  two  or  three  years— I  have  known  but  one  case  to 
persist  any  longer — proves  the  possibility  of  an  indefinite  infectiousness. 

Indeed,  the  infectiousness  of  gonorrhea  in  the  male  is  comparable  to 
that  of  typhoid  fever.  Most  cases  last  an  indefinite  number  of  weeks 
and  are  cured.  A  small  number  continue  infectious.  It  may  be  a  mat- 
ter of  great  delicacy  to  determine  the  persistent  infectiousness  of  a  given 
case.  But  this  does  not  alter  the  fact  that  almost  all  are  cured  within  a 
few  months. 

But  gonorrhea  in  the  female  is  a  very  different  matter.  Conservative 
gynecologists  are  entirely  unwilling  to  set  any  limit  to  its  infectiousness 
and  are  confessedly  incompetent  in  some  instances  to  cure  it,  in  others  to 

^ "  It  has  been  shown  by  a  number  of  observers  that  among  the  poorer  classes 
of  New  York  City,  a  certain  proportion  (commonly  estimated  at  10  per  cent)  of 
female  infants  and  young  children  are  infected  with  gonorrhea,  in  an  active  er 
latent  form,  or  as  germ  carriers.  The  widespread  prevalence  of  this  disease  consti- 
tutes one  of  the  most  difficult  problems  in  hospital  management.  No  institution  or 
hospital  for  children,  however  efficiently  managed,  has  escaped  ward  epidemics  from 
time  to  time.  .  .  . 

"As  an  example  of  typical  conditions,  the  Scarlet  Fever  Service  at  "Willard 
Parker  Hospital  for  1913  will  be  found  instructive:   .  .  . 

"Three  hundred  and  thirty  out  of  791  female  patients  on  admission  had  suf- 
ficient evidence  of  vaginal  infection  to  demand  their  segregation,  and  of  these,  21 
subsequently  developed  clinical  and  bacteriological  evidence  of  the  disease  and  were 
transferred  to  the  infected  wards.  It  is  not  to  be  understood  that  all  of  these  321 
cases  had  gonorrheal  infection  even  in  the  latent  form,  but  experience  goes  to  show 
that  a  large  number  undoubtedly  di<l.  Without  prolonged  and  repeated  examina- 
tions, causing  an  unjustifiable  annoyance  to  the  patients,  this  point  cannot  be 
accurately  determined." — Bull.  N.  ¥.  Health  Dept.,  Mar.  7,  1914. 


104       GONORRHEA:  ITS  SOCIAL  ASPECTS  AND  PREVENTION 

say  whether  it  is  cured  or  not.  I  have  known  a  woman  to  infect  her 
partner  seven  years  after  her  own  infection. 

To  be  sure  most  women,  like  most  men,  recover  from  gonorrhea  in 
a  few  months.  But  the  exceptions  in  women  are  much  more  indefinite 
in  duration,  much  more  difficult  of  diagnosis,  much  more  rebellious  to 
treatment. 

The  vulvovaginitis  of  young  children  is  exceedingly  intractable.  It 
commonly  lasts  for  years. 


GRAVITY  OF  THE  COMPLICATIONS 

The  local  inflammation,  which  is  all  that  most  patients  see  in  a  gon- 
orrhea, is  actually  the  least  of  its  dangers. 

Apart  from  the  danger  of  conjunctival  infection,  which  is  common 
to  both  sexes  but  rare  in  the  adult,  the  complications  due  to  direct  ex- 
tension of  the  disease  are  different  in  the  two  sexes. 

In  man  the  complications  are  almost  entirely  under  the  control  of 
the  skillful  physician  with  a  faithful  patient.  But  both  are  rare,  and 
patients  in  the  poorer  classes  have  neither  the  means  nor  the  leisure  to 
avail  themselves  of  the  resources  of  medicine.  Among  our  dispensary 
patients  the  greater  number  suffer  the  pangs  of  an  acute  posterior  ure- 
thritis, and  some  10  per  cent  to  20  per  cent  suffer  acute  epididymitis, 
which  in  perhaps  one-quarter  of  these  is  bilateral  and  results  in  sterility. 
Chronic  urethritis  or  prostatitis  results  in  fully  70  per  cent  or  80  per 
cent  of  these  cases,  and  severe  urethral  stricture  in  a  small  percentage. 

Sexual  neurasthenia  follows  gonorrhea  in  5  per  cent  to  10  per  cent  of 
clinic  cases. 

Among  our  wealthy  patients,  who  are  well  treated  from  the  onset  of 
their  disease,  epididymitis  complicates  less  than  5  per  cent,  chronic 
urethritis  and  prostatitis  less  than  20  per  cent,  and  stricture  is  alto- 
gether exceptional.  But  even  the  wealthiest  patient  may  not  be  willing 
or  able  to  command  good  treatment  at  the  onset  of  his  gonorrhea,  so 
that  more  than  half  the  patients  treated  in  the  office  of  the  specialist 
suffer  from  chronic  gonorrhea. 

Such  complications  as  prostatic  and  periurethral  abscess  and  pyelo- 
nephritis are  rare  in  the  clinic,  extremely  rare  in  private  practice. 

In  women,  on  the  other  hand,  grave  complications  are  common.  In- 
vasion of  the  uterus,  the  uterine  adnexa,  and  the  peritoneum  were  noted 
in  40  per  cent  of  the  women  reported  to  the  Committee  of  Seven. 

Gonorrhea  reaches  the  uterus  in  20  per  cent,  the  tubes  in  5  per  cent 
of  cases,  says  Schmidt.^ 

This  invasion  of  the  female  generative  organs  takes  places  either  at 

^  ZeitscTir.  f.  Geb.  u.  Gyn.,  vol.  xxi. 


GRAVITY  OF  THE  COMPLICATIONS  105 

the  time  of  infection  or  after  the  birth  of  the  first  child.     For  the  eon- 

D 

orrhea  may  subside  and  become  latent  in  the  glands  of  the  uterine  cervix 
until  pregnancy  excites  a  congestion  that  increases  the  virulence  of  the 
gonococci.  By  these  the  child's  eyes  are  .endangered  at  birth,  its 
mother's  uterus  and  tubes  immediately  thereafter. 

Gonorrhea  of  the  uterus  and  tubes  usually,  though  not  always,-'  im- 
plies sterility.  Hence  this  sterility  is  total  if  the  wife's  tubes  or  uterus 
are  promptly  infected ;  it  is  the  so-called  one-child  sterility  if  they  are 
infected  at  the  time  of  parturition,  l^eisser  and  Bumm  agTee  that  the 
gonococcus  causes  about  30  per  cent  of  sterility  in  women,  while  Mor- 
row states  ^  it  is  responsible  for  fully  half  of  involuntary  sterility. 

But,  besides  depriving  a  woman  of  her  children,  gonorrhea  may  ren- 
der her  a  permanent  invalid,  may  even  cost  her  her  life.  It  is  a  curious 
fact  that  gonorrhea  in  women  is  either  much  milder  or  much  more  severe 
than  the  disease  in  man.  Some  women  are  so  little  inconvenienced  by 
it  that  they  do  not  feel  the  need  of  summoning  a  physician.  Others  are 
overwhelmed  by  acute  salpingitis,  pelvic  abscess,  peritonitis  even;  they 
must  either  undergo  a  capital  operation  or  die.  Still  another  class  suffer 
relatively  less  from  the  tubal  or  uterine  complications  at  first ;  they  are 
not  mortally  ill,  but  they  are  up  one  day  and  down  the  next,  semi-in- 
valids all  the  time,  with  scarce  a  hope  of  release,  unless  it  be  by  oopho- 
rectomy, a  capital  operation,  implying  loss  of  the  faint  remaining  hope 
of  children  and  perhaps  a  continued  invalidism  thereafter. 

Compared  with  these  major  evils  the  danger  of  infection  of  the  eyes 
by  the  fingers  or  to  the  rectum  by  drips  of  vaginal  secretion  is  nothing. 

Children  are  doubly  endangered  by  gonorrhea.  In  the  first  place, 
their  eyes  are  in  imminent  danger  of  inoculation  at  the  moment  of  par- 
turition. From  such  inoculation  is  said  to  result  more  than  one-third  of 
congenital  blindness.^ 

In  the  second  place,  the  infant  or  the  young  child  remains  peculiarly 
susceptible  to  gonorrheal  infection.  Its  eyes  or  its  genitals  may  be  the 
portal.  Gonorrheal  conjunctivitis  and  urethritis  (in  the  male)  present 
no  very  peculiar  characteristics  in  the  infant.  But  gonorrheal  vul- 
vovaginitis in  little  girls  has  a  horror  all  its  own.  The  quite  inex- 
plicable readiness  of  infection,  the  rebelliousness  to  treatment,  the  grave 
and  lifelong  complications,  make  it  seem  one  of  the  crudest  of  known 
maladies. 

The  last  count  in  the  indictment  of  gonorrhea  is  systemic  gonorrhea, 
often  spoken  of  as  gonorrheal  septicemia  or  gonorrheal  rheumatism. 
Systemic  gonorrhea  is  very  grave,  quite  rare,  and  fairly  controllable.  It 
is  gTave  in  that  it  causes  iritis,  endocarditis,  a  very  chronic  type  of 

^  Moskowitz  has  reported  a  tubal  pregnancy  coexisting  with  pyosalpiux. 

'Am.  Jour,  of  Surgery,  1906,  xx,  236. 

»Cf.  Tivnen,  Jour.  A.  M.  A.,  1914,  Ixiii,  1756. 


106       GONORRHEA:  ITS  SOCIAL  ASPECTS  AND  PREVENTION 

chronic  rlieiimatism,  and  many  other  lesions.  It  is,  fortunately,  rare; 
its  frequency  being  estimated  at  about  1  per  cent  of  cases  (Kolle  and 
Hetsch  say  0.7  per  cent;  Ward  says  1.2  per  cent).  Of  its  control  there 
is  no  absolute  certainty.  The  disease  in  most  instances  progresses  slowly 
to  spontaneous  cure.  The  horrors  of  gonorrheal  rheumatism  are  more 
talked  about  than  they  deserve.  Only  20  of  the  5,782  gonorrheics 
in  the  army  were  permanently  incapacitated  by  it. 


SOCIAL  IMPORTANCE  OF  GONORRHEA 

The  social  importance  of  gonorrhea  depends  upon  its  prevalence,  its 
transmissibility,  its  grave  results  in  women  and  children,  and  the  steril- 
ity in  which  it  so  often  results. 

Prevalence. — A  disease  that  attacks  more  than  half  our  young  men, 
a  disease  that  affects  thousands  of  children  and  hundreds  of  thousands 
of  women,  is  important  to  society  by  its  prevalence  alone. 

Transmissibility. — A  disease  that  enters  the  family  almost  ex- 
clusively through  illicit  sexual  contact,  a  disease  that  may  be  transmitted 
long  after  the  patient  thinks  himself  or  herself  well,  a  disease  that  may 
be  transmitted  to  the  wife  from  the  prostitute  via  the  offending  husband, 
a  disease  that  may  be  passed  from  the  wife  thus  innocently  infected  to 
the  eyes  of  her  infant  at  birth  or  to  its  genitals  thereafter,  is  eminently 
important  to  society. 

Grave  Results. — A  disease  that  incommodes  the  man  and  may 
invalid  the  woman,  a  disease  that  is  the  cause  for  most  of  the  major 
gynecology  of  today,  a  disease  that  unsexes  thousands  of  women,  that 
makes  chronic  invalids  of  many,  that  kills  not  a  few,  a  disease  that  in 
this  country  causes  from  one-quarter  to  one-half  of  the  congenital  blind- 
ness, that  is  accountable  for  about  one-third  of  the  blind  in  our  asylums, 
is  a  real  peril  to  society. 

Sterility. — A  disease  that  causes  fully  50  per  cent  of  the  involun- 
tarily sterile,  or  one-child  sterile  marriages,  that  destroys  the  power  of 
procreation  in  man  as  well  as  in  woman,  is  indeed  a  peril  to  the  race. 


SOCIAL  REMEDIES 

Three  types  of  remedy  for  gonorrhea  are  submitted  to  society : 

Individual  prevention. 

Methods  of  dealing  with  prostitutes. 

The  moral  compaign. 
To  discuss  fully  the  relative  merits  of  the  three  would  require  a  vol- 


SOCIAL  REMEDIES  107 

nme.-^  Suffice  it  to  say  here  that  an  individual  preventive,  injection  of 
the  nrethra  after  a  suspicions  intercourse  (p.  225),  though  diminishing 
greatly  the  danger  of  infection,  does  not  entirely  eliminate  it.  Segre- 
gation and  reglementation  of  prostitutes  is  neither  acceptable  nor  suc- 
cessful, while  the  moral  campaign,  the  attempt  to  bring  venereal  dis- 
ease and  all  sexual  matters  out  into  the  light  of  day,  seems  the  only 
way  to  get  at  the  root  of  the  evil. 

Reglementation  is  employed  with  notable  failure  in  France,  with 
mediocre  success  in  Germany.  In  our  country  it  is  impracticable.^  It 
fails  in  theory  by  not  quarantining  the  males,  in  practice  by  not  quaran- 
tining "illicit"  females,  the  lewd  housemaid  or  shop  girl,  and  the  errant 
widow. 

The  moral  campaign  of  education  to  old  and  young  still  has  its  spurs 
to  win.  It  is  very  full  of  promise.  The  notion  that  child  and  bride 
need  education  in  matters  sexual,  and  that  the  boy  needs  clean  ideas  on 
these  subjects  is  a  new  one.  But  it  is  hard  to  see  how  such  education 
can  fail  to  save  many  innocents  from  venereal  disease  and  from  moral 
woes  far  worse. 

^  The  important  publications  on  these  subjects  are  discussed  in  the  various 
societies  of  Sanitary  and  Moral  Prophylaxis  and  of  Social  Hygiene.  Eeference  may 
be  made  to :  Social  Hygiene,  Trans.  Am.  Soc.  Sanitary  and  Moral  Prophylaxis,  Bull, 
sac.  frang.  de  prophylaxis  sanitaire  et  morale,  Mitteil.  Deutsch.  Gesellschaft  z. 
BeTcampf  d.  GescMechtslcranlch. 

^"'The  Social  Evil,"  Putnam  and  Co. 


CHAPTEK   XI 
THE  GONOCOCCUS 

That  the  gonococcus  is  the  cause  of  gonorrhea  is  no  longer  a  subject 
for  discussion.  Ricord's  "recette  pour  attraper  Ja  chaude-pisse"  is  an- 
swered by  the  aphorism  of  Marcel  See:  ''La  plus  helle  femme  du  monde 
ne  pent  donner  que  ce  quelle  a."  ISTo  person  can  impart  or  acquire 
gonorrhea  except  by  imparting  or  acquiring  the  gonococcus. 

The  gonococcus  is  a  nonmobile  diplococcus,  occurring  within  as  well 
as  outside  of  pus  and  epithelial  cells.  It  stains  readily  with  the  familiar 
anilin  dyes.  It  does  not  take  the  Gram.  It  will  not  grow  on  the  usual 
culture  media.  It  produces  endogenous  toxins.  It  cannot  be  inoculated 
upon  animals. 

Microscopic  Characteristics. — When  a  drop  of  gonorrheal  pus  is 
properly  stained  and  examined  through  an  immersion  lens  of  one-twelfth 
aperture,  the  gonococci  seen  present  the  following  characteristics : 

1.  They  are  diplococci.  Each  individual  of  a  pair  is  D-shaped  (cof- 
fee bean  shaped),  with  the  flat  (or  slightly  concave)  border  opposed  to 
its  fellow,  so  that  the  couple  form  an  ovoid  made  up  of  two  separate 
hemispheres.  The  length  of  the  pair  averages  about  l.G/i,  and  the  inter- 
space is  about  half  as  wide  as  either  segment. 

2.  The  diplococci  are  found  grouped  in  pairs,  fours,  and  other  mul- 
tiples of  two,  showing  a  tendency  to  rectangular  disposition,  in  marked 
contrast  to  the  irregular  massing  of  staphylococci  and  the  linear  ar- 
rangement of  streptococci. 

3.  The  gonococcus,  when  it  occurs  in  pus,  is  found  both  within  and 
outside  of  the  pus  and  the  epithelial  cells.^  The  most  characteristic 
groups  are  met  with  inside  the  cells.  The  extracellular  gonococci  may 
be  scattered  or  irregularly  gTOuped,  but  the  intracellular  specimens 
present  a  greater  regularity  of  arrangement.  Without  being  mathe- 
matically distributed,  there  is  still  a  certain  symmetry  in  the  grouping, 
an  absence  of  jumbling,  which  the  observer  soon  learns  to  appreci- 
ate at  a  glance  and  which  our  plates  attempt  to  reproduce  (Plate  IX, 
Figs.  1,  2). 

^  There  is  no  close  clinical  relation  between  the  intracellular  or  the  extracellular 
position  of  the  gonococci  and  the  grade  or  the  stage  of  the  inflammation.  Every 
specimen  contains  gonococci  both  inside  and  outside  the  cells,  and  in  no  definite 
proportion. 

108 


TECHNIC  OF  STAINING  THE  GONOCOCCUS  109 

Such  are  the  characteristics  of  the  gonococcus.  It  is  a  double  D 
diplococcus  occurring  intracellularly  and  in  typical  groups.  But  these 
characteristics  are  sometimes  shared  by  other  bacteria  met  with  in  ure- 
thral pus.  We  must  look  further  for  a  distinguishing  feature.  This 
we  find  in  the  reaction  of  the  gonococcus  to  the  Gram  stain. 

Gram  Eeaction — Gonococci  do  not  take  "the  Gram."  They  are 
"Gram  negative."  This  means  that  if  these  cocci  are  stained  first  with 
an  anilin  dye  and  then  with  Lugol  reagent  (see  below)  the  resultant 
stain  may  be  washed  from  them,  from  the  cells,  from  many  other  bac- 
teria, but  not  from  most  staphylococci  (the  exceptions  are  discussed  on 
page  194)  and  other  cocci  which,  under  the  microscope,  may  otherwise 
resemble  true  gonococci.  Hence,  when  the  Gram  stain  is  applied,  a 
thorough  washing  with  alcohol  leaves  the  cells  and  gonococci  colorless, 
while  the  pseudogonococci  stand  out  in  bold  relief,  stained  darkly  by 
the  combined  color  of  the  anilin  dye  and  the  Gram  stain. 

In  order  to  make  the  effect  of  the  Gram  stain  more  apparent,  it  is 
customary  to  restain  the  cells  and  gonococci  with  a  contrasting  color,  in 
order  that  the  true  gonococci  may  be  visible  for  direct  comparison  with 
the  false  (Plate  II,  Fig.  2). 

Preparation  of  the  Specimen. — From  what  has  been  said  in  the  pre- 
ceding paragraphs,  it  is  clear  that  recognition  of  the  gonococcus  depends 
upon  the  proper  preparation  of  the  specimen — the  proper  performance 
of  the  Gram  test — and  while  the  test  is  not  complicated,  it  is  delicate, 
and,  like  so  many  other  laboratory  methods  that  appear  entirely  simple 
when  one  is  familiar  with  them,  it  does  not  succeed  at  the  hands  of  the 
beginner.  Hence  every  practitioner  is  by  no  means  competent  to  per- 
form and  interpret  the  Gram  stain ;  but  anyone  who  can  smear  a  slide 
and  focus  a  microscope  may  become  competent  by  practice. 

1.  The  Smear. — A  very  small  drop  of  the  pus  to  be  examined  is 
placed  upon  a  clean  glass  slide.  Upon  this  another  slide  is  dropped,  the 
two  pressed  together  and  slid  apart.  This  leaves  each  covered  with  a 
thin  film  of  pus  (the  thinner  the  better) .  Each  is  then  dried  by  evapora- 
tion at  a  gentle  heat  and  fixed  by  rapidly  passing  it  three  or  four  times 
through  the  flame  of  a  spirit  lamp  or  a  Bunsen  burner. 

2.  The  First  Stain. — One  of  the  films  is  now  covered  with  Pal- 
tauf's  solution.-^ 

This  is  left  on  for  three  minutes,  the  excess  washed  off  with  water 
(no  water  must  be  used  if  the  Gram  stain  is  to  be  employed),  the  glass 
dried  in  the  flame,  and  examined  with  the  oil-innnersion  lens.     If  no 

^Anilin  oil,  3  c.c. ;  absolute  alcohol,  7  e.c. ;  distilled  water,  90  c.e.  Shake  for 
two  minutes.  Filter -through  moistened  paper  until  filtrate  is  clear.  Add  two  grams 
of  Griibler's  powdered  gentian  violet.  Set  aside  for  tweuty-four  hours.  Pipette 
supernatant  fluid  as   required. 

This  solution  keeps  well  for  six  weeks. 


110  THE  GONOCOCCUS 

bacteria  witli  the  morphological  characteristics  of  gonococci  are  seen 
after  a  careful  examination,  it  is  a  waste  of  time  to  employ  the  Gram. 
But  if  what  appear  to  be  true  gonococci  are  found,  the  Gram  test  is 
applied  to  the  other  slide.  The  stain  is  applied  for  three  minutes, 
as  above  described,  but  this  time  the  excess  of  solution  must  be  shaken 
from  the  specimen.  No  water  or  alcohol  may  be  applied  at  this  junc- 
ture. The  slide  is  immediately  blotted  and  flooded  with  Lugol's  solu- 
tion. 

3.  The  Lugol. — Lugol's  solution  is  made  up  as  follows : 

lodin — 1  part. 
Potassium  iodid — 2  parts. 
Distilled  water — 300  parts. 
This  is  applied  for  precisely  two  minutes. 

4.  The  Alcohol. — As  soon  as  the  slide  is  removed  from  the  Lugol 
solution  it  should  be  washed  with  absolute  alcohol  for  precisely  thirty 
seconds. 

5.  The  Contrast  Stain. — After  using  various  more  or  less  satis- 
factory counter-stains  I  now  employ  only  the  following: 

Carbolic  acid — 2  parts. 

Saturated  aqueous  solution  of  Bismarck  brown — 98  parts. 

If  the  decolorized  smear  is  covered  with  this  solution  for  three  to 
five  minutes  and  then  rinsed  in  water,  it  acquires  a  light-brown  tint, 
and  under  the  microscope  the  cells  and  gonococci  appear  yellowish 
and  in  marked  contrast  to  the  deep  purple,  almost  black,  pseudogon- 
ococci. 

A  more  prolonged  staining  with  the  brown  gives  the  gonococci  a 
deeper  color,  which  is  not  so  readily  distingTiished  from  that  of  the 
pseudogonococci. 

Such  is  the  technic  of  staining  the  gonococcus,  which  may  be  em- 
ploj^ed  by  anyone  having  an  elementary  familiarity  with  medical  micros- 
copy, and  which  may  be  depended  upon  to  furnish  accurate  results,  if 
followed  accurately.  The  essentials  likely  to  be  overlooked  are  the  em- 
ployment of  Griiblers  violet,  precise  staining,  by  the  watch,  employment 
of  absolute  alcohol,  and  exclusion  of  all  water  until  after  counter- 
staining. 

GONOCOCCUS  CULTURE 

The  gonococcus  can  be  made  to  grow  only  on  special  media  and 
under  special  conditions. 

The  medium  must  contain  human  blood  serum  and  be  slightly  alka- 
line. This  serum  may  be  obtained  from  an  aseptic  effusion  into  the 
peritoneum,  the  pleura,  or  the  tunica  vaginalis.  (Experts  can  obtain 
slight  growth  of  gonococci  upon  ordinary  culture  media.)     • 


PLATE   IX 


3  4 

MiCROPHOTOGRAPHS    OF    GoNOCOCCI    AND    TUBERCLE    BaCILLI. 

Fig.   1. — Gonorrheal  pus.     First  stain:  gentian-violet  solution 

Fig.  2. — Gonorrheal   pus.     Bismarck-brown.     Cells  and  gonococci   take  the  brown  stain,  while 

the  pseudogonococci  remain  black. 
Fig.  3. — Tubercle  bacilli  in  urine. 
Fig.  4. — Smegma  bacilli  in  urine. 


DIAGNOSIS  OF  THE  GONOCOCCUS  111 

Heiman  ^  employs  the  following  culture  medium : 

Sterilized  liquid  chest  serum,  1  part. 

Agar,  2  per  cent  +  peptone,  2  per  cent  +  salt,  0.5  per  cent  +  glu- 
cose, 2  per  cent,  2  parts. 

He  sterilizes  the  liquid  bj  heating  it  to  65°  C.  for  one  hour  for  six 
days,  then  he  leaves  it  three  days  at  the  room  temperature,  then  resteril- 
izes  for  three  days  more. 

The  incubator  must  be  kept  at  a  temperature  between  30°  and  39° 
C.    The  ideal  temperature  is  36°  to  37°  C. 

The  gTOwth  of  gonococci  is  relatively  slow.  They  are  aerobic  and 
facultative  anaerobic.  The  colonies  remain  rounded  and  usually  do  not 
run  together.  They  are  grayish  in  color  and  slightly  translucent. 
Growth  ceases  in  about  forty-eight  hours ;  sooner  if  the  surface  of  the 
agar  dries.  Examination  should  therefore  be  made  at  the  end  of  the 
second  day.  To  continue  the  growth  it  must  be  shifted  to  a  new  medium 
every  three  or  four  days  or  oftener. 

The  vitality  of  the  gonococcus  is  slight  whether  in  smears  or  in 
culture.  Desiccation  kills  it  in  a  few  hours.  But  Heiman  has  culti- 
vated the  gonococcus  from  a  thick  drop  of  pus  twenty-nine  days  old. 
It  is  killed  by  a  temperature  of  45°  C,  and  ceases  to  grow  below  30°  C. 
Any  weak  antiseptic  rapidly  destroys  the  gonococcus  in  vitro.  Cultures 
from  urine  must  therefore  be  made  without  delay  and  before  the  urine 
cools. 

DIAGNOSIS  OF  THE  GONOCOCCUS 

The  gonococcus  is  usually  distinguished  from  staphylococci  and  other 
Gram-positive  cocci  by  the  Gram  stain.  Errors  in  diagnosis  by  the 
Gram  stain  (apart  from  those  due  to  ignorance  and  carelessness)  have 
three  sources,  viz. : 

1.  There  are  other  Gram-negative  cocci  from  which  the  gonococcus 
can  only  be  distinguished  by  culture.^  Such  are  the  micrococcus 
catarrhalis,  the  diplococcus  intracellularis,  and  certain  chromogenic 
cocci. 

Happily  none  of  these  organisms,  except  the  micrococcus  catarrhalis, 
have  been  identified  in  the  genito-urinary  tract.  IN'one  of  them,  except 
the  m.  catarrhalis,  is  believed  to  cause  urethritis.  The  urethritis  caused 
by  m.  catarrhalis  is  probably  insignificant,  and  not  to  be  clinically  mis- 
taken for  acute  gonorrhea.  I  have  encountered  it  but  once  in  several 
hundred  cases. 

^Med.  Record,  1895,  XLVII,  746;  Ihid.,  1896,  L,  887;  Ibid.,  1898,  LIII,  80. 

^Cf.  Zupink,  Berl.  Tclini.  Wochenschr.,  1906,  No.  52;  Wollstein,  Jour,  of  Expcr. 
Med.,  1907,  September  21st;  Elser  and  Huntoon,  Jour,  of  Med.  Research,  1909,  XX, 
No.  4,  p.  369. 


112  THE  GONOCOCCUS 

2.  Apart  from  m.  catarrhalis,  it  must  be  emphasized  that  in  a 
small  percentage  of  cases  the  normal  urethra  (and  in  a  somewhat  larger 
percentage  the  normal  vagina)  contains  Gram-negative  cocci  which  can 
usually  be  differentiated  from  the  gonococcus  by  their  form,  size,  and 
extracellular  position.  These  organisms  fail  to  grow  on  the  ordinary 
culture  media. 

3.  The  most  frequent  source  of  error  is  the  fact  that  the  common 
staphylococci  may  he  Gram-negative  as  well  as  Gram-positive.  As  Crab- 
tree  has  suggested,  this  variability  is  doubtless  due  to  the  presence  or 
absence  of  albumin. 

But  these  confusing  factors,  that  render  the  diagnosis  by  Gram 
alone  quite  valueless,  apply  almost  exclusively  to  chronic  urethritis. 
For  clinical  laboratory  diagnosis  of  acute  genital  gonorrhea  it  is  only 
necessary  to  identify  a  Gram-negative,  intracellular  diplococcus. 

The  gonococcus  in  the  conjunctiva  and  in  joint  exudates  is  equally 
unmistakable. 

Rectal,  buccal,  and  nasal  gonorrhea  require  diagnosis  by  culture. 

The  cultural  characteristics  of  the  gonococcus  have  been  described. 
An  important  feature  in  the  diagnosis  is  that  the  gonococcus  ferments 
glucose  (and  perhaps  maltose,  but  not  other  sugars). 

The  micrococcus  catarrhalis  grows  more  readily  than  the  gonococcus 
on  the  usual  media.  On  serum-agar  it  makes  two  kinds  of  colonies,  the 
one  thick  and  crumbling  like  mortar  does  not  resemble  the  gonococcus, 
the  other  is  quite  similar  to  the  gonococcus,  except  that  the  colony  is 
smaller.  But  the  distinguishing  feature  of  the  micrococcus  catarrhalis 
is  its  inability  to  ferment  glucose. 

The  other  members  of  this  group  grow  more  readily  on  the  familiar 
media.  Thus  the  diplococcus  intracellularis  grows  on  nutrient  or  glycer- 
in-agar  and  on  Loeffler's  blood  serum  agar. 

Concerning  serum  reactions  Elser  and  Huntoon  state  that : 

When  properly  controlled,  agglutination  tests  serve  to  differentiate  the  vari- 
ous groups  from  each  other,  providing  the  strains  tested  are  sutfieiently  agglu- 
tinable.  Diagnostic  difficulties  may  arise  in  connection  with  certain  gonococcus 
strains.  These  are  unusually  sensitive  to  the  action  of  nonnal  and  of  gTOup 
agglutinins  and  may  yield  higher  values  in  the  presence  of  a  meningococcus 
immune  serum  than  moderately  agglutinable  meningococcus  strains. 

Absorption  tests  served  to  differentiate  the  various  groups  of  Gram-negative 
cocci  from  each  other  and  to  establish  the  identity  of  the  agglutinable  and  inag- 
glutinable  meningococcus  strains. 

COMPLEMENT  FIXATION  TEST 

The  gonococcus  complement  fixation  test  of  Schwartz  and  McKeil  ^ 
is  peculiar  only  in  that  the  antigen  employed  is  made  from  mixed 

^  Am.  Jour.  Med.  Sciences,  May,  1911,  December  and  September,  1912;  see  also 


COMPLEMENT  FIXATION  TEST  113 

strains  of  gonococci.  The  original  antigen  was  made  from  eleven 
different  strains  and  as  various  ones  of  these  died  off,  or  were  lost, 
they  have  been  replaced  bj  others. 

The  reaction  becomes  positive  rarely  before  the  fourth  week,  but 
usually  in  the  sixth  to  the  eighth  week.  It  never  becomes  positive  in 
cases  that  are  so  successfully  repressed,  or  aborted,  as  never  to  have 
any  considerable  infection. 

The  reaction  usually  remains  positive  as  long  as  there  is  any  active 
gonorrheal  infection  in  the  patient's  body.  Thus  a  persistent  joint 
lesion  or  tubal  infection  (in  the  female)  may  keep  up  a  positive  reac- 
tion after  the  urethral  infection  has  been  cured.  Two  exceptions  are 
to  be  noted  in  the  time  of  disappearance  of  the  positive  reaction  as  fol- 
lows: 

1.  The  urethral  lesion  may  become  so  slight  and  superficial  that 
the  complement  fixation  test  becomes  negative  before  the  last  gono- 
coccus  has  disappeared.  I  have  never  known  this  to  occur  excepting 
in  cases  of  mild  chronic  anterior  urethritis  that  reacted  brilliantly  to 
the  passage  of  a  sound  in  the  form  of  an  acute  obviously  gonorrheal 
urethritis.  This  check  can,  therefore,  apparently  be  relied  upon  and 
the  combination  of  a  negative  gonococcus  fixation  test  with  absence  of 
reaction  to  the  passage  of  a  sound  is  an  almost  certain  gTiarantee  of 
cure. 

2.  The  fixation  test  usually  remains  positive  two  to  six  weeks 
after  all  clinical  evidence  of  infection  has  disappeared  from  the  urethra 
and  its  glands.  But  it  may  persist  for  months.  Such  a  persistent  posi- 
tive reaction  is  extremely  unusual,  but  I  have  seen  three  men  with  a 
positive  gonococcus  reaction  a  year  after  the  last  trace  of  gonorrhea 
had  disappeared  from  the  urethra ;  each  of  them  was  repeatedly  tested 
by  culture  for  gonococcus  with  negative  results.  Two  of  them  married 
and  did  not  infect  their  wives,  though  the  reaction  of  one  of  these  was 
still  weakly  positive  six  months  after  matrimony.  I  do  not  know 
what  focus  of  infection  kept  up  the  reaction  in  these  cases. 

The  reaction  presents  two  interesting  medico-legal  features : 

1.  If  within  three  weeks  of  the  time  when  a  fresh  urethral  dis- 
charge appeared  the  patient's  blood  is  found  positive  the  discharge  is 
probably  a  relapse  from  a  previous  infection.  If  negative  it  is  doubt- 
less a  new  infection.  The  nearer  the  test  is  made  to  the  beginning  of 
the  infection,  the  more  accurate  it  is  likely  to  be. 

2.  The  reaction  of  a  person  who  has  not  recently  had  a  gonorrhea 
cannot  be  made  positive  by  the  injection  of  gonococcus  vaccines ;  but 
if  the  complement  fixation  test  has  been  positive  witliin  tlic  preced- 

eonfirmatory  articles  by  Swinburne,  Keyes  and  Schmidt,  Am.  Jour.  Med.  Sciences, 
Areh.  of  Diag.,  July,  1911,  Am.  Jour.  Med.  Sciences,  January,  1912;  Trans.  Am. 
Urol.  Assn.,  1911. 


114  THE  GOXOCOCCUS 

iiig  six  months  and  vaccines   are  given   it   is   readily  made  positive 
again. 

Diagnostic  Value. — The  accuracy  of  the  complement  fixation  test, 
like  that  of  the  gonococcus  culture,  varies  in  accordance  with  the  skill 
and  experience  of  the  operator;  hut,  exception  made  for  infection  con- 
fined to  the  anterior  urethra,  technical  errors  are  much  less  likely  to 
interfere  with  the  validity  of  the  complement  fijxation  test  than  with 
gonococcus  culture.  Positive  culture,  on  the  other  hand,  is  more  certain 
evidence  that  an  infectious  lesion  persists  in  the  urethra  than  is  a 
positive  complement  fixation  test.  ISTevertheless  the  practitioner  will 
be  wise  to  rely  more  upon  the  complement  fixation  test  than  upon  any- 
thing else  for  the  diagnosis  of  the  presence  of  gonorrhea. 


GONOCOCCUS  VACCINES 

Christmas  ^  and  Wassermann "  have  shown  that  gonococci  produce 
only  an  endotoxin  derived  from  dead  and  disintegrated  microorganisms. 
Thus  the  toxin  may  be  measured  in  units  of  bacteria.  Accordingly, 
one  speaks  of  a  solution  containing  20,000,000  or  1,000,000,000  dead 
gonococci,  meaning  a  solution  containing  the  toxins  of  that  number  of 
dead  bacteria. 

The  vaccine  is  sold  in  phials  containing  20,000,000  to  500,000,000 
dead  gonococci  to  the  c.c. 

Autogenous  and  Stock  Vaccines — Teague  and  Torrey  ^  have  shown 
that  the  serum  of  an  animal  immunized  to  one  strain  of  gonococcus 
does  not  cause  fixation  of  complement  when  tested  against  an  antigen 
obtained  from  another  strain.  Following  up  this  line  of  investigation 
Torrey  was  able  to  diiferentiate  eleven  strains  of  gonococci  in  Xew  York 
City,  and  most  of  the  stock  vaccines  now  sold  are  from  a  mixture  of 
these  eleven  strains. 

It  is  difiicult  to  compare  the  efiicacy  of  autogenous  and  stock  vac- 
cines on  a  scientific  basis.  Autogenous  vaccines  have  the  advantage 
of  giving  a  definite  product  distinctly  and  certainly  applicable  to  a 
given  case,  but  they  have  the  disadvantage  of  requiring  from-  two  to 
four  days'  preparation.  We  cannot  get  them  at  the  time  when  we 
most  need  them. 

Local  pain  from  the  injection  is  slight,  local  inflammatory  reaction 
rare.  General  toxic  or  febrile  reactions  are  not  unusual  if  the  vaccine 
treatment  is  begim  at  a  high  dose  or  pushed  rapidly.    But  the  discomfort 

*  Am.  Institut  Pasteur,  1900,  XLV,  331. 
'Berl.  Min.  Wochensclir.,  1897,  No.  32. 
^  Jour,  of  Med,  Sesearch,  December,  1907. 


GONOCOCCUS  VACCINES  115 

of  a  reaction  accompanied  by  a  temperature  of  103°  F.  and  lasting  not 
more  than  twelve  hours  is  the  most  that  may  be  expected. 

Dosage. — The  vaccines  have  been  employed  at  an  average  dose  of 
10,000,000  to  20,000,000,  increased  to  a  maxinmm  of  50,000,000.  Such 
doses  are  too  small.  One  should  begin  at  40,000,000  or,  in  acute  cases, 
60,000,000  and  increase  by  20,000,000  or  more  at  each  dose  (unless  the 
symptoms  are  controlled,  or  the  reaction  is  marked)  until  a  dose  of 
200,000,000  is  reached.  Only  in  exceptional  cases  is  it  necessary  to  go 
higher  than  this. 

The  injections  are  given  into  the  muscle.  They  should  not  he  re- 
peated oftener  than  every  other  day. 

Results.  1 — Gonococcic  vaccines  have  been  employed  in  various 
classes  of  cases,  viz. : 

In  localized  gonorrhea — 

Acute  urethritis. 

Chronic  urethritis. 

Vulvovaginitis. 
In  complications  of  local  gonorrhea — 

Epididymitis. 
In  systemic  gonorrhea — • 

Acute  arthritis  or  iritis. 

Chronic  arthritis. 

Sepsis. 

Localized  Gonokehea. — So  long  as  gonorrhea  remains  localized 
upon  the  genital  and  urinary  mucous  membranes  it  excites  no  systemic 
reaction,  and  is  seemingly  uninfluenced  by  the  injection  of  vaccines.  In- 
dividual instances  of  the  cessation  of  an  intractable  gonorrhea  under  the 
administration  of  vaccines  prove  nothing.  Chronic  gonorrhea  is,  as  a 
rule,  quite  uninfluenced  by  the  vaccine  treatment.  I  have  not  even 
noted  an  increase  in  the  gonococci  in  the  urethral  discharge,  though 
certain  Continental  authorities  rely  upon  the  vaccine  to  excite  a  dis- 
charge if  gonococci  are  present  (focal  reaction). 

Genital  Complications. — It  is  my  practice,  whenever  a  gonor- 
rheic  develops  fever  or  any  symptoms  suggestive  of  acute  epididymal, 
prostatic,  or  peri-urethral  complications,  to  administer  50,000,000 
gonococci  and  to  follow  this  two  days  later  by  the  same  dose  if  all  is 
well,  by  double  the  dose  if  the  symptoms  continue. 

One  may  thus  perhaps  abort  the  threatened  complications. 

When  the  metastatic  (e.  g.,  epididymal)  focus  is  estal)lishcd,  how- 
ever, I  have  seen  no  positive  good  result  from  vaccine. 

^Cole  and  Meakins,  Bull.  JoMs  Uoplcins  University,  1901;  Irons,  Jour,  of  Infect. 
Bis.,  .June- July,  1908;  Ballenger,  Jour.  Am.  Med.  Assoc,  May  ;50,  1908,  p.  1784; 
Van  Rienipst,  Polyclinic  Med.  Jour.,  1909. 


116  THE  GONOCOCCUS 

Systemic  Gonokehea. — The  vaccine  treatment  finds  its  most  ra- 
tional application  in  the  treatment  of  systemic  gonorrhea.  Thus  many 
authorities  rely  upon  frequent  injections  of  from  50,000,000  to  500,- 
000,000  killed  gonococci.  I  at  one  time  believed  in  this  treatment; 
but  a  large  experience  at  Bellevue  Hospital  has  left  me  utterly  skepti- 
cal. 

In  the  second  place,  the  painful  lesion  of  many  so-called  cases  of 
chronic  gonorrheal  arthritis  is  an  organic  one,  an  exostosis  or  a  change 
in  ligament  or  synovial  membrane  due  to  a  gonococcal  inflammLiion  that 
has  passed,  and  preeminently  imsuited  to  any  vaccine  treatment. 

Gonorrheal  septicemia  sometimes  reacts  brilliantly,  sometimes  not 
at  all.     Autogenous  vaccines  should  be  used  if  possible. 


ANTIGONOCOCCUS  SERUM 

The  antigonococcus  serum  employed  in  this  country  is  that  of 
Rogers  and  Torrey.^  The  serum  is  polyvalent  (like  the  vaccine).  It 
is  derived  from  rams,  since  their  serum  seems  much  less  toxic  than  that 
of  goats  or  rabbits. 

Technic. — Two  c.c.  of  the  serum  are  injected  every  day  or  every 
second  or  third  day. 

Complications — With  ram  serum  the  only  reaction  that  one  may 
anticipate  is  a  varying  amount  of  local  swelling,  redness,  heat  and  sore- 
ness around  the  point  of  injection.  This  does  not  occur  by  any  means 
in  every  individual  case,  and  is  not  caused  by  any  antibody  in  the 
serum,  but  is  due  to  the  local  toxic  action  of  the  serum  itself.  As  the 
same  serum  has  been  found  to  cause  this  reaction  in  one  individual 
but  not  in  another,  it  is  partly  referable  to  the  idiosyncrasy  of  the 
patient  (Rogers). 

Results. 2 — The  results  reported  from  the  use  of  the  serum  are  quite 
similar  to  those  reported  from  the  vaccine.  I  have  not  experimented 
with  the  serum. 

Rogers  claims  good  results  in  85  per  cent  of  early  joint  cases,  and 
some  good  in  late  cases  if  treatment  is  continued  for  a  month  or  more. 
Herbst,  using  three  times  the  usual  dose,  achieved  very  satisfactory  re- 
sults in  all  chronic  joint  cases,  but  nothing  in  epididymitis  and  acute 
arthritis.  Swinburne  warmly  advocates  the  serum  at  the  onset  of 
epididymitis,  stating  that  in  27  cases  so  treated  the  pain  was  relieved 
in  forty-eight  hours. 

^  Jour.  Am.  Med.  Assoc,  January  27,  1906,  and  September  14,  1907. 

^Rogers  and  Torrey,  loc.  cit.;  Herbst,  Jour.  Am.  Med.  Assoc.,  May  23,  1908, 
Swinburne,  Jour.  Am.  Med.  Assoc.,  January  26,  1907,  and  Med.  Eecord,  November 
14.  1908. 


IMMUNITY  117 


IMMUNITY 


The  gonococcus  confers  a  relative  immunity  to  the  person  who 
harbors  it.  He  can  usually  not  be  reinfected;  e.g.,  by  a  woman  upon 
whom  he  has  conferred  the  disease.  Moreover,  relapses  of  a  given  gon- 
orrhea are  almost  invariably  less  severe  than  the  initial  outbreak. 

But  the  immunity  that  persists  after  a  cured  gonorrhea  is  of  the 
slightest.  Subsequent  attacks  are  usually  milder  than  the  initial  one; 
but  they  may  be  quite  as  prolonged,  quite  as  complicated. 


CHAPTEK    XII 

GONORRHEA:  THE  EXTRAGENITAL  TYPES  OF  INOCULATION;  THE 
SYSTEMIC  MANIFESTATIONS 

The  gonococcus  is  specific  to  the  human  race.  It  is  impossible  to 
give  gonorrhea  to  any  animal. 

The  gonococcus  may  be  inoculated  readily  in  the  eye,  in  the  urethra 
of  either  sex,  and  in  the  female  genital  passages.  The  rectum  is  less 
vulnerable  than  the  genitals.  The  mouth  and  nose  are  all  but  immune. 
The  unbroken  skin  cannot  be  inoculated,  and  all  squamous  epithelium 
offers  a  marked  resistance.  Thus  the  urinary  bladder,  the  preputial 
cavity  of  the  male  and  the  vagina  of  the  female  suffer  rarely  and,  as  a 
rule,  mildly  from  gonorrhea,  except  in  so  far  as  they  are  involved  in  the 
contiguous  inflammation  of  the  urethra,  the  cervix,  or  the  vulva. 

That  children  are  much  more  vulnerable  to  gonorrhea  than  adults 
is  evidenced  by  the  readiness  with  which  little  girls  acquire  vulvovagin- 
itis, the  frequency  of  gonorrheal  conjunctivitis  in  children,  and  the  fact 
that  nasal  and  buccal  gonorrhea  occur  almost,  if  not  quite,  exclusively 
in  children. 

EXTENSION  OF  THE  DISEASE 

Gonorrhea  of  the  eye  and  rectum  remain  localized.  In  the  genitals 
the  disease  extends  by  continuity  as  far  as  the  vesical  trigone,  and 
throughout  the  genitalia  of  both  man  and  woman. 

The  gonococcus  penetrates  the  epithelium  of  the  inflamed  surface 
and  excites  exudation  and  subsequently  sclerosis  in  the  subjacent  con- 
nective tissue ;  but  it  shows  no  gTcat  tendency  to  cause  lesions  to  any 
depth  except  when  shut  in  by  inflammatory  occlusion  of  the  orifice  of  a 
gland.  Under  such  circumstances  it  may  cause  abscess,  invade  the  veins 
(thrombosis),  and  be  carried  to  distant  parts  of  the  body,  there  to  set  up 
metastatic  gonorrheal  foci. 

Clinically  this  local  suppuration  and  general  intoxication  occur  al- 
most exclusively  in  the  genitals ;  i.e.,  the  urethra,  prostate,  vesicle,  and 
epididymis  of  the  male,  the  glands  of  the  urethra,  vagina  and  cervix, 
and  the  fallopian  tubes  in  the  female. 

By  means  of  the  blood  stream  gonococci  may  be  carried  to  almost  any 
organ.  The  favored  locations  for  systemic  gonorrhea  are  the  joints  and 
the  iris.    Less  frequently  it  attacks  the  bursae,  the  tendon  sheaths,  the 

118 


ANORECTAL  GONORRHEA  119 

pleura,  the  meninges,  the  periosteum,  the  parotid  gland,  the  veins,  the 
endocardium,  the  pericardium,  the  muscles. 

Lymphatic  absorption  is  uncommon  and  gonorrheal  lymphangitis 
and  lymphadenitis  rare. 

Absorption  of  gonorrheal  toxins  may  affect  the  nervous  system  or 
the  skin. 

The  peritoneum  is  not  rarely  involved  in  gonorrheal  salpingitis,  but 
gonorrheal  peritonitis  is  extremely  rare  in  the  male.  The  kidneys  are 
probably  reached  by  gonococci  from  the  blood  stream,  though  direct  in- 
vasion from  an  infected  bladder  is  not  impossible. 


ANORECTAL  GONORRHEA 

The  anus  is  relatively  immune  to  the  gonococcus.  Every  acute  vul- 
var gonorrhea  pours  pus  over  it,  and  yet,  even  in  infants,  it  is  not  often 
inflamed.  Jullien  ^  has  collected  from  the  statistics  of  Howard,  Schultz, 
and  Baer,  1,037  cases  of  genital  gonorrhea  in  women  with  157  inocula- 
tions of  the  anus.  Eichom  ^  noted  anal  infection  in  72  out  of  235 
cases. 

Etiology. — Sodomy  is  the  accepted  cause  for  anal  gonorrhea  in  men ; 
but  in  women  the  infection  is  more  often  due  either  to  direct  inoculation 
by  pus  from  the  vulva  or  by  indirect  inoculation  from  the  douche  tube 
or  the  finger. 

Pathology. — The  lesions  are  both  deep  and  chronic.  The  epithelium 
of  the  rectum  is  eroded,  infiltrated,  and  in  places  ulcerated  for  several 
inches  up  from  the  anus. 

Fissure  and  condyloma  are  common;  the  anus  itself  is  infiltrated. 
Ischiorectal  abscess  and  phlebitis  of  the  hemorrhoidal  veins  have  been 
noted  as  rare  complications.  Whether  or  not  rectal  gonorrhea  is  often 
a  cause  of  stricture  is  not  determined.  The  stricture  is  usually  obsei*\'ed 
so  late  that  its  cause  is  not  clear. 

Symptoms — The  symptoms  are  so  slight  that  the  condition  is  often 
overlooked.  At  the  onset  there  is  at  most  itching  and  burning.  Later 
there  are  to  all  intents  and  purposes  no  subjective  symptoms. 

Physical  Signs. — The  lesion  is  rather  rectal  than  anal.  The  anal 
orifice  may  be  swollen;  it  is  almost  alwa,ys  fissured — "at  six  o'clock," 
as  the  French  say.  A  single  moist,  pointed,  soft  condyloma  usually 
overhangs  the  fissure.  There  is  often  no  external  discharge,  1)ut  a 
drop  of  pus  may  readily  be  expressed  by  pressure  from  the  roctum. 
Proctoscopy  reveals  tumefaction,  erosion,  and  ulceration  of  the  rectum. 

*  Le  Blennorrhagie  (formes  rares  et  peu  connues),  Paris,  1906.    Also  Brunswick- 
]e  Bihan,  Bull,  de  I' Acad,  de  Med.,  Paris,  1907,  LXXI,  p.  497. 
'^  Dermatolog.  Zeitschr.,  1909,  XVI,  No.  7. 


120         EXTRAGENITAL  TYPES  OE  GONORRHEA 

Duration — Rectal  gonorrhea  is  extremely  chronic.  Jullien  treated 
four  successive  cases  116,  169,  and  174  days  before  achieving  a  cure. 

Diagnosis. — The  gonococcus  may  be  identified  in  the  pus.  If  the 
condition  of  the  genitals  leaves  any  doubt  as  to  the  nature  of  the  inflam- 
mation, the  diagnosis  should  be  verified  by  culture. 

Treatment — The  rectum  may  be  irrigated  daily  with  potassium  per- 
manganate (1:  200  to  1:  25)  or  with  protargol  (2  per  cent  to  10  per 
cent).  Erosions  and  ulcers  may  be  touched  every  second  or  third  day 
with  a  nitrate  of  silver  pencil. 


BUCCAL  AND  NASAL  GONORRHEA 

That  gonorrheal  inflammation  of  the  mouth  and  nose  may  occur  we 
cannot  doubt.  That  it  does  occur  in  infants  may  be  considered  proven. 
But  its  existence  in  the  adult  is  at  best  uncertain. 

The  existence  of  buccal  gonorrhea  in  infants  was  proven  by  Ahl- 
feld.-^  Kimball  "  has  reported  8  cases  of  systemic  gonorrhea  in  in- 
fants, one  or  more  of  whom  were  doubtless  infected  from  the  mouth. 
De  Stella  ^  has  apparently  proven  the  existence  of  infantile  nasal 
gonorrhea. 

In  adults,  however,  we  hear  only  of  sporadic  cases.  The  cases  col- 
lected by  Jullien  fall  under  two  heads,  those  in  which  urethral  gonorrhea 
has  been  attributed  to  coitus  ab  ore  (cases  of  Howard  and  Honnorat) 
and  those  in  which  stomatitis  (cases  of  Cutler,  Petit,  Columbrine, 
Juergens,  and  four  of  Menard)  or  rhinitis  (cases  of  Duncan  (1784), 
Forcade,  Edwards)  are  alleged  to  be  gonorrheal. 

The  evidence  against  nasal  gonorrhea  in  the  adult  is  summed  up  in 
the  experiments  of  Diday  and  Bormiere,  who  strove  in  vain  to  inoculate 
the  nasal  mucosa  with  gonorrheal  pus.  The  clinical  cases  in  favor  are 
rare,  ancient,  and  unconvincing. 

Buccal  gonorrhea  is  fortified  by  more  modern  instances.  But  the 
alleged  gonococcus  found  may  perfectly  well  have  been  the  meningococ- 
cus or  micrococccus  catarrhalis,  and  the  "intense"  stomatitis  is  precisely 
what  one  would  not  expect. 

A  typical  report  has  recently  been  made  by  Juergens.'*  The  stoma- 
titis was  intense,  the  gums  ulcerated,  the  breath  fetid.  Bacteriologic 
examination  revealed  the  "gonococcus"  and  the  bacteria  of  Vincent's 
angina. 

In  this  instance  the  stomatitis  was  doubtless  a  Vincent's  angina,  the 

^  Berl.  Jclin.  Wochenschr.,  October  19,  1896. 
'Med.  Record,  1903,  LXIV,  761. 
^Deutsche  med.  Zeitschr.,  1899,  No.  1. 
*  Berl.  Tclin.  Wochenschr.,  June  13,  1904. 


SYSTEMIC  GONOERHEA  121 

"gonococcus"  a  micrococcus  catarrlialis.     Until  such  cases  are  tested  by 

culture  we  cannot  form  a  final  decision. 

Clinical   Picture — In  infants  the   inflammation   appears  to  be   a 

severe  one  and  always  confined,  curiously  enough,  either  to  nose  or 

mouth.    In  some  instances  nasal  gonorrhea  has  accompanied  ophthalmia 

neonatorum  and  has  been  attributed  to  infection  through  the  lacrimal 

duct. 

The  duration  of  the  inflammation  is  a  few  weeks,  as  a  rule- 
Treatment. — Antiseptic  mouth  wash  and  nasal  spray  effect  a  speedy 

cure.     Argyrol  in  20  per  cent  solution  is  the  best  wash,  but  frightfully 

dirty. 

SYSTEMIC  GONORRHEA 

The  gonococcus  invades  the  system  through  the  blood  stream.  Its 
toxins  may  be  absorbed  by  the  same  route.  Though  no  one  has  disproven 
the  participation  of  gonococcus  toxins  in  the  causation  of  the  local 
lesions  of  systemic  gonorrhea,  the  gonococcus  has  so  frequently  been 
found  in  the  pus  of  joints  and  on  the  vegetations  of  heart  valves  and 
even  in  the  blood  ^  that  such  lesions  are  attributed  to  the  bacterium 
itself,  leaving  certain  rare  and  manifestly  toxic  phenomena  attributed  to 
the  toxin. 

Toxic  Lesions — Skin  lesions,  neuroses. 
Bacterial  Lesions — Arthritis,  osteo-arthritis. 

Endocarditis,  pericarditis. 

Bursitis,  tenosynovitis. 

Periostitis,  osteitis. 

Myositis,  abscess. 

Iritis,  systemic  conjunctivitis. 

Phlebitis,   thrombosis. 

Pleurisy,  pneumonia,  parotitis. 

!Neuritis,  meningitis  (  ?). 

Erythema  and  Neurosis — Erythema,  urticaria,^  pruritus,^  and  vari- 
ous neuroses  may  occur  during  gonorrhea  and  may  be  relieved  by  cure 
of  the  gonorrhea. 

The  feeling  of  disgust,  even  amounting  to  neurasthenia,  excited  by 
"venereal"  disease  is,  of  course,  purely  psychic.  Sexual  neurasthenia 
is  not  peculiar  to  gonorrhea. 

^  Irons,  Arch.  hit.  Med.,  Dec,   1909. 

'  Orlipski,  Miinch.  med.  Wochenschr.,  October  7,  1902. 

^  Domenici,  Gaz.  degli  osp.,  March  1,  1903. 


122  EXTRAGENITAL  TYPES  OF  GONORRHEA 


GONORRHEAL  ARTHRITIS 

Gonorrheal  arthritis  or  gonorrheal  rheumatism,  as  it  is  commonly 
called,  is  the  commonest  type  of  metastatic  gonorrhea. 

Occurrence. — Gonorrheal  rheumatism  is  said  to  occur  in  about  1  per 
cent  of  persons  afflicted  with  urethral  gonorrhea.  Children  are  par- 
ticularly prone  to  it  and  may  develop  it  from  slight  local  lesions.  Thus 
Kimball  ^  found  10  cases  of  gonorrheal  arthritis  among  70  children. 
Women  are  much  less  often  affected  than  men,  doubtless  because  they 
lack  seminal  vesicles.  I^orthrup  ^  reports  230  cases  in  the  male  to  22  in 
the  female.  It  has  been  noted  by  Fournier  as  early  as  the  fifth  day 
after  the  onset  of  gonorrhea,  but  is  commonest  between  the  third  and 
the  fifth  week.  It  may  occur  at  any  time  while  the  patient  harbors 
gonococci. 

Certain  cases  show  a  marked  tendency  to  relapse  of  joint  sjnnptoms 
with  each  new  attack  of  gonorrhea.  Fournier  and  Keyes,  Sr.,  have 
each  recorded  an  instance  of  four  such  relapses  in  a  single  patient,  and 
Brandes  has  seen  six. 

Etiology — Retention  of  pus  in  the  seminal  vesicles  is  believed  to  be 
the  usual  cause  of  gonorrheal  rheumatism.  We  do  not  yet  know  how 
broad  this  rule  may  be. 

Distribution. — The  lesions  are  often  polyarticular.  Among  ITorth- 
rup's  cases  76  per  cent  showed  involvement  of  three  or  more  joints. 
Moreover,  synovitis,  bursitis,  and  the  other  lesions  of  systemic  gonorrhea 
are  often  associated  with  joint  lesions. 

The  knee  is  the  joint  most  frequently  affected  (two-thirds  of  Four- 
nier's  120  cases,  one-third  of  Finger's  ^  375,  seven-eighths  of  Bone- 
man's  278  cases). 

!N^orthrup's  statistics  show  gonorrhea  of  the  knee  in  91  cases,  of  the 
ankle  in  57,  of  the  foot  in  40,  of  the  wrist  in  27,  of  the  heel  and  toes  in 
21,  of  the  elbow  in  18,  of  the  hip  and  shoulder  16  each,  of  the  hand 
in  11. 

The  association  of  gonorrhea  with  spondylitis  has  been  suggested 
by  Bouchard  ■*  and  Chute. ^ 

Pathology — Gonorrheal  arthritis  is  but  a  single  expression  of  a  gen- 
eral infection.  Like  other  forms  of  septic  arthritis,  it  depends  upon 
bacterial  localization,  either  in  the  joint  itself  or  in  the  articular  extrem- 
ity of  the  bone.  Hence  the  two  distinct  types  of  the  disease,  gonorrheal 
arthritis  and  gonorrheal  osteo-arthritis. 

^Medical  Hecord,  1903,  LXIV,  761. 

^Presbyterian  Hospital  Beport   (New  York),  1896,  vol.  i,  p.  53. 

'Archiv  f.  Derm.  u.  Syiih.,  1894,  XXVIII,  2,  296. 

* Zeitschr.  f.  Tclin.  Med.,  1907,  LXII.  'Boston  Med.  and  Surg.  Jour.,  1904. 


GONORRHEAL  ARTHRITIS  123 

Clinical  Types. — The  onset  may  be  acute  or  subacute.  If  acute,  the 
inflammation  begins  like  an  attack  of  acute  articular  rheumatism,  with 
pain,  redness,  swelling,  tenderness,  and  disability.  But  there  are  no 
sweats;  the  brilliant  redness  and  exquisite  sensitiveness  of  acute  artic- 
ular rheumatism  are  not  seen,  and  fever  is  relatively  slight. 

A  subacute  onset  varies  in  intensity  from  a  mere  ache  with  local 
tenderness  to  a  moderately  severe  pain  with  some  swelling  and  consid- 
erable disability. 

The  duration  of  the  inflammation  is  characteristically  prolonged, 
although  exceptionally  an  intense  attack  is  brief.  The  mildest  lesion 
may  hang  on  for  weeks  and  months. 

The  severity  of  the  inflammation  is  moderate  as  compared  to  other 
types  of  septic  arthritis.  There  is  more  or  less  thickening  of  the  soft 
tissues,  and  usually  no  great  exudation  within  the  joint.  Yet  excep- 
tionally the  joint  may  be  filled  with  a  purulent  exudate  and  be  the 
cause  of  intense  sepsis. 

Complications. — The  complications  due  to  direct  extension  from  the 
joint  are  bursitis,  tenosynovitis,  and  infiltrations  of  the  surrounding 
tissues.  Abscess  outside  the  joint,  as  in  the  case  reported  by  Ware,^  is 
even  rarer  than  suppurative  arthritis.  Implication  of  the  bone  is,  as 
stated  above,  primary  and  not  secondary. 

The  results  of  gonorrheal  arthritis  depend  upon  the  treatment  and 
the  nature  of  the  lesion.  Osteo-arthritis  may  even  result  in  total  de- 
struction of  the  joint  with  bony  ankylosis.  The  worst  that  simple 
arthritis  can  do  is  to  cause  fibrous  ankylosis.  The  most  discouraging 
features  of  the  prognosis  are  the  marked  tendency  to  chronicity,  and 
the  tendency  to  relapse  after  apparent  cure. 

Diagnosis. — The  diagnosis  of  acute  gonorrheal  rheumatism  occur- 
ring during  the  course  of  gonorrhea  is  not  difficult.  Under  these  cir- 
cumstances marked  swelling  in  a  joint,  with  slight  constitutional  dis- 
turbances, is  very  suspicious.  A  positive  complement  fixation  test  for 
gonococcus  confirms  the  diagnosis.  The  para-articular  involvement 
gives  the  swelling  a  characteristic  fusiform  shape. 

Acute  gonorrheal  rheumatism  occurring  in  the  absence  of  gonococcic 
urethral  lesion  (as  in  the  children  reported  by  Kimball)  may  be  diag- 
nosed by  the  complement  fixation  test,  or  by  identification  of  the 
gonococcus  in  the  fluid  aspirated  from  the  joint.  But  this  fluid,  whether 
serous,  seroflbrous,  or  purulent,  is  usually  quite  sterile. 

Chronic  gonorrheal  arthritis  must  be  dift'erentiated  by  the  comple- 
ment fixation  test  from  other  forms  of  septic  arthritis.  Nathan  ^ 
insists  that  thougli  gonorrheal  arthritis  may  be  recurrent,  it  is  never 
really  chronic,  and  that  the  cases  called  chronic  "are  tiicse  in  which 

^  N.  Y.  Med.  Jour.,  .January  13,  1906. 
'Ibid.,  Mar.  16,  1907. 


124         EXTRAGENITAL  TYPES  OF  GONORRHEA 

the  initial  acute  inflamination  has  left  behind  bands  of  adhesion  or 
other  structural  change  in  the  synovial  membrane  in  arthritis,  and  bone 
outgrowths  or  ankylosis  in  osteo-arthritis.  These  changes,  unless  treated 
mechanically  or  by  operation,  are  permanent." 

Prophylaxis — Among  the  gonorrheal  patients  I  have  treated  from 
the  onset  of  their  disease  not  one  has  developed  systemic  gonorrhea. 
This  is  in  a  measure  the  dispensation  of  a  kind  Providence,  but  it  is 
primarily  a  result  of  the  proper  treatment  of  the  disease  in  its  early 
stages.  The  local  treatment  of  acute  gonorrhea  almost  certainly  pre- 
vents systemic  gonorrhea. 

The  injection  of  vaccines  at  the  first  appearance  of  the  fever  in  the 
course  of  a  gonorrhea  also  has  a  prophylactic  effect. 

Curative  Treatment. — Inasmuch  as  acute  gonorrheal  arthritis  is  but 
one  lesion  in  a  general  systemic  infection,  the  patient  should  be  consid- 
ered septic  and  the  possibility  of  further  systemic  gonorrhea  should  be 
recognized.  He, should  be  put  to  bed  and  the  urethral  source  of  infec- 
tion vigorously  attacked.  Inasmuch  as  the  seminal  vesicles  are  be- 
lieved to  be  the  usual  source  of  infection,  these  glands  should  be  mas- 
saged. The  precise  status  of  vesiculotomy  in  the  treatment  of  gonor- 
rheal rheumatism  is  not  yet  precisely  defined.  It  unquestionably  cures 
some  cases  and  fails  to  cure  others  (p.  245). 

The  joint  should  be  immobilized  and  Bier  hyperemia  employed 
throughout  the  acute  stage.  A  light  plaster-of-Paris  bandage  or  splint 
affords  the  best  immobilization  and  does  not  interfere  with  the  Bier 
treatment.  The  patient  should  not  be  permitted  to  use  the  affected  limb 
before  the  acute  inflammation  has  subsided,  however  mild  this  be. 

The  one  way  to  prevent  permanent  changes  in  and  about  the  joint  is 
by  careful  local  treatment  during  the  acute  stages.  The  beneficial  effect 
of  the  Bier  treatment  cannot  be  doubted.-^ 

The  specific  vaccines  and  sera  afford  little  relief  (p.  114).  One  or 
the  other  should  always  be  employed.  ''Hot-air"  baking  ^  has  much 
the  same  effect  as  the  Bier  treatment. 

If  the  tension  within  the  joint  is  not  promptly  relieved  by  immo- 
bilization and  passive  hyperemia,  the  fluid  should  be  aspirated.  The 
presence  of  pus  in  the  joint  is  not  of  itself  an  indication  for  more  vig- 
orous surgical  measures,  for  it  is  likely  to  be  spontaneously  absorbed. 
But  if  the  pus  persists,  arthrotomy  should  be  performed  and  the  joint 
irrigated  with  1 :  2,000  nitrate  of  silver  solution. 

As  the  acute  symptoms  subside  the  diagnosis  should  be  accurately 
made  between  arthritis  and  osteo-arthritis.  The  former  requires  that 
the  immobilization  be  prolonged  and  passive  motion  begun  cautiously, 

'       -^  Cf.  Bier,  "  Hyperaemia  als  Heilsmittel.  "     Baetzner,  Deutsche  ZeitscJir.  f.  Chir., 
1907.     Von  Tiling,  Jour.  Am.  Med.  Assn.,  April  29,  1905,  p.  135. 
=  Wagner,  Med.  Klin.,  IV,  June  21,  1906. 


GONORRHEAL  ENDOCARDITIS  125 

the  latter  that  passive  motion  should  be  begim  early,  before  the  splint  is 
left  off,  and  that  massage,  passive  motion,  and  splints  be  used  until 
function  is  entirely  restored. 

Exostosis  of  the  Os  Calcis.i— Though  first  described  as  recently  as 
1906  (by  Baer),  this  condition  is  so  common  and  so  painful  as  to  merit 
special  mention.  It  begins  as  a  myositis  or  periostitis  at  the  attach- 
ment of  the  flexor  brevis  digitorum  to  the  tubercle  of  the  os  calcis. 
With  the  subsidence  of  the  acute  inflammation  an  exostosis  forms, 
pressure  upon  which  (in  walking)  is  exquisitely  painful.  The  diagnosis 
is  made  by  radiography.  The  treatment  is  operation.  The  exostosis 
must  be  chiselled  or  scraped  away  after  exposure  through  an  incision 
alono'  the  inner  side  of  the  heel. 


GONORRHEAL  ENDOCARDITIS 

Systemic  gonorrhea  produces  heart  lesions  in  from  10  per  cent  to  20 
per  cent  of  cases.  Thus  ISTolan  recognized  heart  lesions  of  probable  gon- 
orrheal origin  in  16  out  of  115  cases  of  gonorrheal  arthritis  and  Sears  ^ 
in  25  out  of  167. 

Sears  has  analyzed  68  cases  of  gonorrheal  endocarditis,  of  which  61 
were  in  men,  7  in  women.  The  heart  lesion  was  associated  with  ar- 
thritis in  56  cases,  in  48  of  which  the  lesions  involved  three  or  more 
joints,  while  in  10  there  were  no  joint  lesions.  The  heart  was  involved 
during  the  first  gonorrhea  certainly  in  31  cases,  probably  in  9  more. 
In  one  instance  the  heart  is  alleged  to  have  been  involved  during  the 
second  day  of  a  gonorrhea.  As  a  rule  the  lesion  was  first  noted  during 
the  fifth  or  sixth  week. 

Pathology — The  lesions  are  usually  confined  to  the  heart  valves. 
Exceptionally  there  is  pericarditis  or  myocarditis.  'Tn  38  cases  the 
mitral  valve  alone  was  involved,  in  12  the  aortic,  and  in  2  the  pulmonic. 
The  mitral  and  aortic  were  both  involved  in  8,  the  mitral  and  tricuspid 
in  1,  the  aortic  and  pulmonic  in  1"  (Sears). 

The  pathologic  changes  ^  in  the  valves  usually  consist  in  small 
friable  vegetations  made  up  of  plasma  cells,  leukocytes,  and  red  blood- 
corpuscles  in  a  loose  framework.  Sometimes  the  valve  is  exulcerated, 
even  perforated.  Gonococci  may  usually  be  cultivated  postmortem  from 
the  lesions  and  sometimes  antemortem  from  the  blood. 

Clinical  Tjrpes. — Two  clinical  types  are  recognized,  viz.,  simple  gon- 

^Winthrop,  Jour.  A.  M.  A.,  1909,  LIII,  715. 

''Boston  City  Hosp.  Ecports,  1898,  IX,  201. 

=  Cf.  Eosenthal,  Berl.  Idin.  Wochenschr.,  November  26,  1900;  Thayer  aixl  La/.aer, 
Jour,  of  Exper.  Med.,  1899,  IV;  and  Thayer,  Am.  Jour,  of  the  Med.  ScL,  November, 
1905. 


126         EXTRAGENITAL  TYPES  OF  GONORRHEA 

orrlieal  endocarditis  and  malignant  gonorrheal  endocarditis,  l^eitlier 
type  shows  any  clinical  peculiarity  to  stamp  it  as  gonorrheal.  The  for- 
mer is  mild  and  insidious  in  onset,  perhaps  entirely  latent,  so  that  the 
resultant  murmur,  perhaps  recognized  years  after,  may  be  the  only 
symptom.  The  malignant  type,  on  the  other  hand,  usually  begins 
abruptly  with  chill,  and  progTesses  with  intense  septic  fever.  Yet  the 
types  are  neither  fixed  nor  exclusive ;  a  case  may  begin  mildly  and  be- 
come malignant  later,  or,  beginning  in  the  most  acute  fashion,  it  may 
rapidly  subside. 

Dia^osis — A  patient  who  develops  a  heart  murmur  or  malignant 
endocarditis  while  suffering  from  gonorrheal  rheumatism  may  be  put 
down  as  a  case  of  gonorrheal  endocarditis.  This  diagnosis  is  con- 
firmed by  the  complement  fixation  test  or  the  cultivation  of  gonococci 
from  the  blood.^ 

Prognosis. — Sears  believes  that  a  mitral  lesion  offers  a  better  prog- 
nosis than  any  other,  since  of  the  43  cases  in  his  series  that  recovered,  33 
gave  signs  of  lesions  in  that  valve. 

Cardiac  symptoms,  if  present,  usually  persist  a  month  to  six  weeks, 
septic  symptoms  two  to  four  weeks.  The  damage  to  the  valve  is  usually 
permanent  and  the  murmur  persists.  Fatal  cases  usually  terminate  in 
two  or  three  weeks,  but  the  patient  may  survive  several  months. 

Treatment — The  treatment  is  that  of  endocarditis  plus  the  anti- 
gonococcus  vaccine  or  serum. 

^Lofaro,  II  PolicUnico,  Feb.,  1911,  No.  2,  p.  49. 


CHAPTER    XIII 

OCULAR  GONORRHEA 

It  is  convenient  to  group  in  one  chapter  infectious  gonorrheal  con- 
junctivitis and  the  ocular  lesions  of  systemic  gonorrhea,  though  the  re- 
lations between  them  are  anatomic  and  biologic,  but  not  clinical.  The 
gonococcus  does  not  invade  the  system  from  the  conjunctiva. 

INFECTIOUS  GONORRHEAL  CONJUNCTIVITIS 

The  frequency  of  gonorrheal  conjunctivitis  in  infants  and  its  rarity 
in  adults  has  been  mentioned  in  Chapter  X. 

The  infection  is  due  to  contact  with  gonorrheal  pus,  derived  from 
the  mother's  genitalia  during  parturition  or,  in  after  life,  from  contact 
with  dirty  fingers. 

Symptoms — The  incubation  period  is  believed  to  be  from  twelve  to 
forty-eight  hours  in  adults.  In  infants  the  inflammation  first  shows 
itself  on  the  third  or  fourth  day.  In  adults  one  eye  is  usually  spared  if 
properly  protected,  but  in  infants  the  lesion  is  commonly  bilateral. 

The  onset  is  hyperacute,  as  a  rule.  The  subjective  symptoms  of 
burning  and  itching  are  promptly  exchanged  for  intense  and  constant 
pain.  The  lids  are  intensely  red  and  swollen.  They  must  be  forced 
apart  to  obtain  a  view  of  the  globe.  The  ocular  conjunctiva  is  intensely 
inflamed  and  so  swollen  that  it  overhangs  the  cornea,  which  thus  seems 
sunk  into  the  depths  of  the  globe.  The  subconjunctival  edema  soon 
interferes  with  the  circulation  of  the  cornea,  which  is  usually  more  or 
less  necrosed.  This  corneal  necrosis  or  ulceration,  if  situated  near  the 
periphery,  may  be  concealed  during  the  acute  attack  by  the  overhanging 
conjunctiva. 

The  pain  completely  exhausts  the  patient,  but  there  is  no  fever. 

The  corneal  destruction  results  in  opacities  which,  if  central,  destroy 
the  vision.  Perforation  of  the  cornea  results  in  prolapse  and  involve- 
ment of  the  iris.     Iritic  adhesions  may  occur  without  perforation. 

Prognosis — The  infection,  though  rarer,  is  usually  much  more 
severe  in  adults  .than  in  infants.  The  sight  of  an  adult  is  rarely  saved, 
that  of  an  infant  often  is. 

The  duration  of  the  acute  disease  is  from  two  to  six  weeks,  a  mild 

127 


128  OCULAR  GONORRHEA 

conjunctivitis  persisting  as  long  again.  It  may  leave  a  pseudotrachoma. 
Corneal  destruction  is  often  far  less  than  would  be  expected  from  the 
intensity  of  the  inflammation.  Glaucoma  may  supervene  in  a  badly 
damaged  eye. 

If  an  eye  is  destroyed  by  gonorrheal  or  other  purulent  inflammation 
the  danger  of  sympathetic  inflammation  of  the  opposite  eye  is  very 
slight,  if  it  ever  occurs  (Knapp).  It  is  not,  therefore,  proper  to  remove 
the  stump  for  fear  of  this  dreaded  complication,  a  fact  well  to  bear  in 
mind,  because  a  shriveled  stump  of  an  eye  furnishes  a  base  of  support 
for  an  artificial  eye. 

Diagnosis — Almost  every  hyperacute  purulent  conjunctivitis  is 
gonorrheal  and  almost  every  gonorrheal  conjunctivitis  is  purulent.  The 
microscope  determines  the  diagnosis.  There  is  a  pseudogonorrheal  con- 
junctivitis neonatorum  of  relatively  mild  type,  not  uncommon  in  insti- 
tutions.    This  accounts  for  a  large  percentage  of  cases. 

Prophylaxis — An  antiseptic  should  be  dropped  into  the  eyes  of 
every  child  at  birth.  There  are  no  exceptions  to  this  rule  of  practice. 
The  antiseptic  usually  instilled  is  2  per  cent  silver  nitrate,  as  advised 
by  Crede.^ 

The  adult  exercises  prophylaxis  by  keeping  his  fingers  clean  and  out 
of  his  eyes.  I  have  never  known  a  case  of  gonorrheal  conjunctivitis  in 
my  private  practice. 

Treatment. — The  sick-room  should  be  kept  dark,  the  patient  in  bed. 

Local  treatment  must  be  properly  instituted.  Delay  may  jeopardize 
the  eye.     The  essentials  of  treatment  are  three: 

1.  Antiphlogosis :  Cold. 

2.  Cleanliness :  Irrigation. 

3.  Antiseptics :  Bactericides. 

The  gTeatest  possible  care  is  necessary  in  handling  the  tender  swollen 
eye.    No  pressure  is  allowable. 

All  dressings  should  be  the  lightest  possible,  and  tenderly  placed  by 
a  delicate  hand.  The  swollen  upper  lid  is  already  weight  enough.  The 
utmost  care  should  be  used  in  protecting  the  sound  eye  from  contagion. 
Buller's  shield,  a  watch  glass  set  into  perforated  squares  of  rubber 
plaster,  is  not  so  good  as  Knapp's  suggestion,  a  mica  spectacle  plate  (to 
be  obtained  from  any  optician)  fastened  on  with  rubber  plaster  strips. 
This  is  transparent,  very  light,  and  does  not  steam. 

All  operative  measures  are  categorically  contra-indicated  during  the 
active  period  of  the  disease. 

Cold  applications  are  of  the  utmost  importance.  Their  application 
must  be  unremitting  night  and  day,  and  for  this  reason  two  or  even  three 
trained  nurses  are  necessary.  Thin  compresses,  chilled  in  ice  water, 
should  be  placed  upon  the  closed  lid,  being  renewed  about  every  five 

>  Cf.  Jour.  Am.  Med.  Assn.,  1909.  LIV,  876. 


SYSTEMIC  OCULAR  GONORRHEA  129 

minutes  night  and  day.  The  cold  must  not  be  too  intense  during  the 
decreasing  stage,  as  it  may  interfere  with  the  nutrition  of  the  cornea — 
an  interference  which  manifests  itself  by  a  misty  appearance  commenc- 
ing at  the  center  of  the  cornea.  Should  this  be  noticed,  the  cold  appli- 
cation must  be  stopped  at  once. 

Cleanliness  and  antisepsis  must  be  constantly  assured  by  gently 
separating  the  lids  and  freely  instilling  with  a  dropper  (not  a  syringe, 
for  fear  of  spattering  the  pus  into  the  eye  of  the  attendant),  argyrol 
in  such  strength  as  the  patient  can  bear  (usually  20  per  cent)  ;  a  few 
minims  being  dropped  into  the  inflamed  eye  every  half  hour  or  every 
hour  until  the  acute  inflammation  begins  to  subside  and  the  discharge 
becomes  mucopurulent.  Thereafter  2  per  cent  nitrate  of  silver  solution 
is  applied  once  or  twice  a  day  until  gonococci  can  no  longer  be  found 
in  the  secretions. 


SYSTEMIC  OCULAR  GONORRHEA 

The  various  lesions  that  may  occur  in  the  eye  as  a  result  of  systemic 
gonorrhea  are  enumerated  as  follows  by  Byers  ^ : 

Iritis  (Mackenzie),  conjunctivitis  (Fournier,  1866),  iridochoroid- 
itis  (Koeniger,  1872),  keratitis  (Colsmann,  1882),  panophthalmitis 
(Martin,  1882),  optic  neuritis  (Panas,  1890),  dacroadenitis  (Panas, 
1894),  retinitis  (Burckhardt,  1894),  tenovitis  (Puech,  1895),  throm- 
bosis of  the  retinal  vessels  (Galezowski,  1900). 

Iritis  and  Iridocyclitis — The  lesion  is  not  very  common.  Lap- 
ersonne  saw  one  or  two  cases  among  2,000  eye  cases  and  Kurka  two  in 
20,000.  In  Byers's  cases  it  was  always  preceded  (62  cases),  accom- 
panied (9  eases),  or  followed  (10  cases)  by  gonorrheal  rheumatism. 
It  was  unilateral  in  48  cases,  bilateral  in  23  in  the  first  attack ;  uni- 
lateral in  16,  bilateral  in  3  in  relapses. 

Byers  recognizes  the  following  types:  Iridocyclitis  (mild  or  severe), 
plastis  iridochoroiditis  (which  may  exceptionally  proceed  to  suppura- 
tion), exudative,  relapsing,  and  hemorrhagic  iritis. 

The  lesions  are  not  clinically  distinguishable  from  similar  lesions 
due  to  other  cause  except  by  the  concurrence  of  genital  and  joint  gon- 
orrhea or  by  the  complement  fixation  test. 

Conjunctivitis — The  lesion  was  bilateral  in  42  cases,  unilateral 
twice.     In  3.5  per  cent  there  were  other  ocular  lesions,  usually  keratitis. 

The  symptoms  are  rather  mild,  the  secretion  usually  mucoid  or 
mucopurulent.     There  was  conjunctival  edema  in  half  the  cases,  sweli- 

*" Gonorrheal  Ocular  Metastases,"  Montreal,  1908.  The  statistics  throughout 
are  from  this  monograph.  In  each  case  the  name  of  the  discoverer  and  the  date  of 
discovery  are  placed  in   parenthesis. 


130  OCULAR  GONORRHEA 

ing  of  the  lids  in  only  10  per  cent.  Both  ocular  and  bulbar  conjunctivae 
were  usually  involved.  Gonococci  were  found  in  the  discharge  in  many 
cases.  The  average  duration  was  two  weeks,  with  five  and  forty-six 
days  as  extremes.     Relapses  were  rare  and  the  prognosis  good. 

Retinitis — The  lesion  is  a  neuroretinitis  (bilateral  six  times,  uni- 
lateral five  times).  Six  of  Byers's  cases  recovered  and  three  terminated 
in  atrophy. 

Other  Lesions — The  other  ocular  lesions  of  systemic  gonorrhea 
enumerated  above  are  rare  and  occur  as  complications  of  iritis  or  con- 
junctivitis. 

Diagnosis. — The  diagnosis  of  these  lesions  as  gonorrheal  depends 
almost  solely  on  the  concurrence  of  genital  gonorrhea  and  gonorrheal 
arthritis  and  on  the  complement  fixation  test. 

The  discovery  of  gonococci  in  the  secretion  from  the  inflamed  con- 
junctiva proves  the  nature  of  the  lesion,  but  may  leave  doubt  as  to 
whether  gonorrheal  conjunctivitis  is  systemic  or  local.  Systemic  con- 
junctivitis is  likely  to  be  mild,  bilateral,  and  accompanied  by  other 
ocular  lesions ;  it  is  always  associated  with  genital  gonorrhea  and  gon- 
orrheal arthritis.  Local,  virulent  conjunctivitis,  on  the  other  hand,  is 
not  associated  necessarily  with  any  other  lesions  of  the  disease,  and 
is  usually  an  intense,  unilateral  inflammation. 

Treatment Instillation  of  20  per  cent  argyrol  solution  every  three 

hours  is  of  benefit  for  systemic  conjunctivitis.  Other  local  treatment  is 
along  general  lines;  e.g.,  atropin  for  iritis,  etc. 

The  urethra  must  be  vigorously  attacked,  as  in  every  type  of  sys- 
temic gonorrhea. 

The  toxins  or  serum  should  be  administered,  though  they  have  not 
proven  very  successful. 


CHAPTER    XIV 

GONORRHEAL  VULVOVAGINITIS  IN  CHILDREN 

By  Dr.  E.  D.  Baeeinger 

This  disease  is  generally  found  in  the  children  of  the  poorer  classes, 
where  overcrowding  and  unhygienic  surroundings  predispose  to  its 
transference.  Dirty  towels,  soiled  linen,  etc.,  are  the  usual  media  of 
contagion ;  often  a  direct  history  can  be  traced  through  the  mother  who 
is  unaware  of  the  nature  of  her  leukorrhea  to  the  father  who  has  an 
active  gonorrhea.  Trentwith  ^  states  that  50  to  75  per  cent  of  his  cases 
showed  the  father  to  be  indirectly  responsible  for  the  infection. 

In  hospitals,  asylums,  and  especially  nurseries,  an  epidemic  is  often 
due  to  lack  of  recognition  of  the  nature  of  the  discharge  and  carelessness 
in  handling  it. 

Such  epidemics  in  institutions  may  usually  be  traced  back  to  one  or 
two  children.  Sheffield  showed  that  one  little  girl  with  vulvovaginitis 
conveyed  the  infection  through  the  medium  of  a  large  bath  tub,  in  which 
twenty  to  thirty  of  the  children  had  been  bathed  at  one  time. 

Though  epidemics  of  gonorrhea  in  children  occur  in  the  above-stated 
manner,  many  individual  cases  are  due  to  rape.  In  the  crowded  tene- 
ment districts  this  is  not  an  infrequent  occurrence,  probably  arising  in 
many  cases  from  the  prevalent  superstition  that  coitus  with  a  virgin 
will  cure  an  attack  of  gonorrhea. 

Yet  this  infection  is  by  no  means  confined  to  the  children  of  the 
poor.  Oftentimes  most  virulent  and  intractable  cases  have  been  found 
in  a  fashionable  girls'  school,  or  in  the  home  of  luxury,  where  the  dis- 
ease has  occasionally  been  traced  back  to  the  erring  nursemaid. 

The  prevalence  of  this  infection  among  children  has  been  estimated 
in  various  clinics  where  these  children  have  been  brought  for  treatment. 
Welt-Kakel  -  reports  that  in  ten  years,  1893-1903,  in  her  service  at  the 
Mount  Sinai  Hospital  Dispensary  she  had  190  cases  (1.6  per  cent)  of 
vulvovaginitis  among  a  total  of  11,578  cases  treated.  She  further  states 
that  "Pott  mentions  1  per  cent,  while  Henock  found  1  in  1,500  children. 
The  statistics  of  the  Armenkinderspital  in  Pesth  shows  a  percentage 
of  0.7  per  cent  among  32,875  children;  at  the  Armenkinderspital  in 

^N.  Y.  Medical  Journal,  February  3,  1906. 

'N.  Y.  Med.  Jour,  and  Phila.  Med.  Jour.,  October  8-29,  1904. 

131 


132  GONORRHEAL  VULVOVAGINITIS  IN  CHILDREN 

Graz,  15  cases  of  gonorrheal  vulvovaginitis  were  found  in  the  year 
1890  in  a  service  of  4,501  children,  vi^hile  Seiffert  found  among  3,414 
sick  children  at  the  Polyclinic  22  cases."  Dr.  Welt-Kakel  states  her 
cases  did  not  occur  epidemically,  but  were  isolated  cases  which  presented 
themselves  during  her  service. 

Morbid  Anatomy  and  Pathology — The  organ  most  usually  involved 
in  children  is  the  vulva. 

The  vagina  also  is  usually  involved,  and  the  area  of  gTeatest  inflam- 
mation is  at  the  vaginal  outlet,  around  the  hymen,  where  the  gonorrheal 
discharge  passes  over  the  perineum. 

The  gonococcus  rarely  burrows  beneath  the  deeper  layer  of  the  epi- 
thelium. 

The  gonococcus  is  usually  found  in  the  discharges. 

Symptoms — The  incubation  period  of  gonorrhea  seems,  on  the 
whole,  to  be  of  shorter  duration  in  children  than  in  the  adult ;  three  to 
four  days  is  the  time  given  by  Cohena-Brach  and  Luczny  (Welt-Kakel). 

The  child  first  complains  of  pain  on  walking,  or  of  a  burning  or 
'^itching"  on  urination,  and  the  mother  notes  a  discharge. 

There  is  usually  considerable  edema  of  the  labia  majora,  which  are 
more  or  less  stuck  together  with  the  copious  purulent  discharge  which 
pours  out  from  the  vagina.  Underlying  the  dried  discharge  there  are 
often  erosions,  which  bleed  easily — the  inflammatory  condition  may  ex- 
tend to  the  skin  surrounding  the  vulva  and  may  affect  the  inner 
aspects  of  the  thigh.  And  there  is  often  an  accompanying  inguinal 
adenitis. 

On  gently  separating  the  labia  pus  is  usually  found  oozing  through 
the  vaginal  outlet.  If  the  pus  be  wiped  away  and  the  child  cry  or  cough, 
often  more  pus  will  be  expressed  through  the  opening,  showing  that  the 
vagina  is  involved. 

In  cases  due  to  violation  the  accompanying  trauma  may  be  very  con- 
siderable— the  hymen  may  be  ruptured  or  the  whole  perineal  floor  torn 
through.  In  one  such  case  observed  by  me  the  traumatism  was  so  ex- 
treme that  the  whole  perineum  was  destroyed  and  the  vulva  black  and 
gangrenous  appearing.  (The  child  in  this  instance  was  in  shock  when 
first  seen.) 

In  many  cases  of  violation  there  has  not  been  any  penetration  and 
the  hymen  may  be  quite  intact.  Bandler  states  that  by  playing  a 
stream  of  water  under  mild  pressure  against  the  hymen  the  delicate, 
fringelike  edge  can  be  examined  to  see  if  an  injury  has  been  inflicted. 

By  inserting  a  very  small  Ferguson  speculum  (modification  by 
Bandler)  or  a  Kelly  speculum  No.  X,  with  the  child  in  the  knee-chest 
position,  the  vagina  can  be  entirely  examined,  and  the  cervix  brought 
into  view  and  inspected  as  to  discharge. 

In  the  ordinary  uncomplicated  cases  of  vulvovaginitis  there  is,  as  a 


GONORRHEAL  VULVOVAGINITIS  IN  CHILDREN  133 

rule,  only  a  slight,  if  any,  elevation  of  temperature,  and  but  mild  con- 
stitutional disturbance. 

Diagnosis. — The  finding  of  the  gonococcus  in  the  discharge  estab- 
lishes the  diag-nosis.  In  view  of  present  uncertainties  in  regard  to  the 
bacteriology  (of  vulvovaginitis)  it  would  not  seem  sufficient  to  base  a 
diagnosis  on  a  smear  showing  a  Gram-negative  diplococcus.  Before 
pronouncing  a  final  diagnosis  a  culture  should  be  made.  This  should  be 
insisted  upon  in  cases  of  possible  medicolegal  import.  A  sufficiently 
accurate  working  diagnosis  for  clinical  purposes,  however,  can  be  made 
by  the  finding  of  the  Gram-negative  diplococcus  in  a  smear  taken  from 
a  given  case. 

Differential  diagnosis  must  be  made  from  noninfectious  vulvovagin- 
itis, which  arises  from  a  variety  of  causes,  such  as  lack  of  personal 
cleanliness,  soiled  diapers,  decomposed  smegma,  sweat,  urine,  the 
oxyuris,  or  pin-worms  from  the  rectum.  In  hot  weather,  and  especially 
with  exercise,  these  conditions  arise  more  readily. 

There  is  also  the  so-called  "catarrhal"  form  of  vulvovaginitis, 
which  clinically  resembles  gonorrhea,  but  does  not  show  the  gonococcus ; 
the  bacteriology  of  this  other  still  seems  to  be  obscure.  This  form,  how- 
ever, is  infections. 

!N"oninfectious  vulvovaginitis  may  complicate  some  of  the  infectious 
diseases;  e.g.,  measles  and  scarlet  fever. 

Course  of  the  Disease. — The  acute  inflammatory  stage  usually  lasts 
from  four  to  six  weeks.  After  this  the  discharge  is  apt  to  change  in 
character  from  a  profuse  thick  to  a  thin  serous  flow  and  the  case  to  be- 
come subacute  or  chronic.  The  duration  of  the  disease  varies  greatly ; 
many  cases  extend  over  a  number  of  years.  The  average  time  for  cure 
has  been  variously  estimated  at  four  to  six  months. 

In  children  as  in  adults  gonorrhea  is  prone  to  relapse.  Often  after 
an  apparent  cure  the  trouble  starts  up  suddenly,  and  gonococci  reappear 
in  the  discharge. 

Complications — The  complications  of  vulvovaginitis  are  very  nu- 
merous. Though  extension  of  the  infection  to  the  bladder  is  rare  in 
children,  Wertheim  has  reported'  a  case  of  true  gonorrheal  cystitis  in  a 
little  girl,  where  the  gonococcus  was  found  in  a  piece  of  bladder  mucous 
membrane  removed  by  an  operating  cystoscopy 

Extension  of  the  infection  from  the  cervix  through  nterus  and  tubes 
on  into  the  peritoneum  may  give  any  of  the  surgical  complications  which 
the  gynecologist  finds  in  the  adult,  as  salpingitis,  pyosalpinx,  or  purulent 
peritonitis.  These  cases  are  often  diagnosticated  as  appendicitis,  but 
examination  of  the  vaginal  secretion  usually  reveals  the  gonococcus. 
The  course  of  a  pure  gonorrheal  peritonitis  is  usually  more  favorable 
than  that  of  a  mixed  infection. 

Extension  of  the  gonorrheal  process  to  the  anus  and  rectum  may  take 


134  GONORRHEAL  VULVOVAGINITIS  IN  CHILDREN 

place.  Arthritis  is  one  of  the  more  frequent  complications ;  gonorrheal 
conjunctivitis  also.  In  fact,  any  of  the  systemic  manifestations  of  gon- 
orrhea may  occur.  Sequelae  are  usually  adhesions  of  the  uterus,  tubes, 
and  ovaries. 

Treatment. — In  the  early  stages,  while  there  is  edema  of  the  vulva 
and  profuse  discharge,  it  is  preferable  to  keep  the  child  in  bed.  The 
mother  or  nurse  should  be  instructed  in  the  careful  handling  of  all 
infectious  materials. 

The  diet  should  be  light,  avoiding  any  highly  seasoned  food  and 
plenty  of  fluid  should  be  taken.  The  bowels  should  be  kept  freely  open. 
Once  or  twice  a  day  the  child  should  be  put  in  a  warm  sitz  bath. 

If  the  discharge  is  confined  to  the  vulva  or  is  very  profuse  there,  it 
is  well  at  first  to  confine  the  irrigations  to  the  vulva  only. 

The  degree  of  vaginal  involvement  can  be  fairly  well  estimated  by 
the  method  mentioned  above — wiping  away  the  pus  over  the  vaginal 
opening  and  observing  if  more  pus  oozes  down  when  the  child  cries  or 
strains. 

The  irrigation  used  for  the  vulva  should  be  copious  hot  flushings  of 
a  2  per  cent  boric  acid  solution  while  the  inflammation  is  very  acute. 
This  should  soon  be  changed  to  a  bichlorid  of  mercury  (1 :  10,000- 
5,000)  solution,  lysol  (|  to  1  per  cent)  or  potassium  permanganate 
(1:2,000). 

If  the  vagina  is  obviously  badly  involved  from  the  first,  vaginal 
douches  should  also  be  given  without  delay,  the  above  solution  (slightly 
diluted)  being  used,  and  two  quarts  used  at  a  time. 

The  best  douche  outfit  is  a  soft-rubber  catheter,  'No.  15,  F.,  attached 
to  a  glass  irrigating  jar  or  ordinary  fountain  bag.  The  pressure  should 
be  mild. 

The  child  is  placed  in  the  dorsal  position  over  a  Kelly  pad  douche 
pan.  The  catheter  should  be  introduced  with  great  care  so  as  not  to  in- 
jure the  delicate  hymen.  The  douches  should  be  given  twice  or  thrice 
daily,  oftener  if  needed  to  wash  away  the  discharge. 

After  each  douche  the  vulva  should  be  gently  dried  and^  oint- 
ment applied  so  as  to  protect  the  delicate  skin  from  the  excoriating 
effect  of  the  discharge. 

A  light  absorbent  vulva  dressing  should  be  applied  and  held  securely 
in  place  between  treatments  so  as  to  avoid  any  conveyance  of  pus  to  the 
eyes  by  means  of  the  child's  fingers. 

After  the  first  acute  stage  is  over,  the  vulva  should  be  painted  thor- 
oughly with  argyrol  5  to  25  per  cent,  protargol  2  to  4  per  cent,  or  silver 

*Zinc  oxid  ointment  has  been  found  by  some  to  be  very  useful  for  this  purpose; 
others  recommend  an  ointment  containing  one  of  the  silver  salts  as  a  2  per  cent 
protargol  ointment  (Handler).  The  writer  has  found  the  use  of  these  silver  oint- 
ments to  be  most  efficacious. 


GONORRHEAL  VULVOVAGINITIS  IN  CHILDREN  135 

nitrate  1  per  cent.  The  vagina  should  also  have  instillations  of  any  of 
these  solutions,  treatment  to  either  vulva  or  vagina  being  given  once  a 
day  immediately  following  the  douching.  The  instillations  into  the 
vagina  can  be  made  readily  by  the  use  of  a  glass  medicine  dropper. 

Gradually  the  daily  treatments  can  be  changed  to  thrice  and  then 
twice  weekly.  If  the  vaginitis  persists,  it  may  be  necessary  to  give 
direct  applications  to  the  vaginal  or  cervical  mucous  membrane. 

These  applications  should  be  made  with  the  child  in  the  knee-chest 
position  and  by  means  of  a  small  Ferguson  or  Kelly  ISTo.  X  speculum. 
The  hymen  should  be  anesthetized  by  a  pledget  of  cotton  soaked  in  2 
per  cent  alypin,  which  is  allowed  to  remain  there  for  five  to  ten  min- 
utes. Light  is  thrown  in  by  means  of  a  hand  mirror  and  the  cervix  or 
vagina  examined  carefully. 

Erosions  of  the  cervix  or  vagina  can  be  touched  up  with  a  3  to  5  per 
cent  silver  nitrate  solution,  and  if  the  vagina  is  extensively  involved  it 
may  be  filled  with  a  1  per  cent  silver  nitrate  solution,  which  is  allowed 
to  remain  there  for  a  few  minutes. 

As  improvement  takes  place  the  silver  irrigation  can  be  replaced  by 
zinc-sulphate  irrigation  (solution  to  about  -J  per  cent  strength)  or  zinc 
and  alum  (3j)  to  water  (Oj). 

From  time  to  time  the  discharge  should  be  examined  for  gonococci 
and  active  treatment  continued  so  long  as  these  are  found. 

When  the  discharge  no  longer  shows  them  and  the  complement  fixa- 
tion test  becomes  negative  a  tentative  cure  may  be  pronounced  and 
treatment  stopped. 

In  view  of  the  tendency  of  the  recurrences,  it  is  wise  to  reexamine  at 
intervals  of  months  and  later  every  year  or  two.  Of  course  this  is  only 
practicable  where  the  physician  has  the  cooperation  of  an  intelligent 
parent  or  guardian. 

Prophylaxis — The  safeguarding  of  children  of  the  community  from 
the  ravages  of  gonorrhea  seems  so  vital  a  duty  that  it  is  only  necessary 
to  mention  the  more  important  ways  in  which  this  can  be  furthered. 

All  adults  in  active  gonorrhea,  especially  those  who  have  children, 
should  be  warned  of  the  great  infectiousness  of  the  disease  and  that 
little  girls  are  apt  to  contract  it.  Specific  instructions  should  be  given 
in  regard  to  the  destruction  of  all  soiled  dressings,  proper  disinfection  of 
hands,  and  importance  of  separate  sleeping  and  toilet  arrangements. 

Violation  is  a  crime  which  should  be  followed  up  more  severely  by 
the  hand  of  the  law.  It  should  be  a  matter  of  civic  responsibility  to  see 
that  these  cases  are  brought  to  justice.  And  yet  one  familiar  witli  the 
tragedies  of  the  slums  often  sees  these  cases  sink  into  oblivion  with  no 
questions  asked. 

In  hospitals,  asylums,  day  nurseries,  or  institutions  where  children 
are  congregated,  the  utmost  care  should  be  taken  in  regard  to  the  admis- 


136  GONORRHEAL  VULVOVAGINITIS  IN  CHILDREN 

sion  of  children  with  leukorrhea.  Many  of  the  leading  hospitals  at  pres- 
ent will  not  admit  a  girl  to  their  children's  wards  without  taking  a 
vaginal  smear. 

When  gonorrheal  vulvovaginitis  has  once  gotten  into  such  an  insti- 
tution the  most  careful  and  intelligent  isolation  and  treatment  should  be 
carried  out. 

If  possible  such  cases  should  be  isolated  as  completely  as  measles  or 
scarlatina.  Where  separate  nurses  are  not  possible,  extra  precautions 
should  be  taken  to  insure  asepsis  in  going  from  one  case  to  the  next. 
All  thermometers,  towels,  douche  outfits,  bath  tubs,  and  toilet  articles 
should  be  kept  separate  for  these  cases  and  should  be  scrupulously  dis- 
infected before  and  after  using.  The  nurses  should  be  especially  in- 
structed in  the  disinfection  of  their  hands  and  be  provided  with  rubber 
gloves  if  possible.  Where  the  babies  are  still  in  the  diaper  age,  gauze 
dressing,  which  can  be  destroyed,  should  be  substituted.  Diapers  or 
dressings  of  any  kind  which  are  used  again  should  be  most  carefully 
boiled. 

Dr.  Holt  has  drawn  attention  to  the  fact  that  one  of  the  most  trying 
features  about  prophylactic  measures  is  the  length  of  time  they  must  be 
persisted  in. 


CHAPTER    XV 
GONORRHEA  IN  WOMEN 
By  De.  E.  D.  Barringer 

There  is  probably  no  infection  which  appears  in  a  greater  variety 
of  forms  to  tax  the  skill  and  judgment  of  the  medical  practitioner  than 
gonorrheal  infection  in  the  female.  Its  almost  infinite  variety  of  clin- 
ical pictures,  its  frequently  obscure  onset,  its  insidious  progress,  make  it 
often  difficult  of  diagnosis.  Again,  the  sociologic  questions  which  ac- 
company this  infection  still  further  complicate  the  problem  of  treat- 
ment. 

It  is  of  importance  to  consider  some  of  the  causes  which  have  com- 
bined to  make  this  infection  in  the  female  sex  so  much  more  of  an 
elusive  factor  to  deal  with  than  in  the  male.  Foremost  of  these  is  the 
actual  anatomical  difference  in  the  conformation  of  the  genito-urinary 
organs  of  the  two  sexes. 

In  the  female  the  extent  of  mucous  membrane  which  may  be  in- 
volved is  enormous  in  comparison  with  the  male.  The  vulva  with  its 
intricate  folds,  the  urethral  orifice  with  its  glands,  the  vagina  and 
cervix,  around  which  the  gonococci  are  usually  deposited,  the  uterii<;3 
with  its  endometrium  rich  in  glands,  the  fallopian  tubes,  the  ovaries,  to 
the  peritoneum,  present  one  continuous  trail  for  gonorrheal  invasion. 

Again,  as  this  disease  practically  always  results  from  sexual  inter- 
course, and  frequently  from  illicit  intercourse,  the  question  of  gonorrhea 
has  gone  hand  in  hand  with  the  history  of  prostitution.  The  sociologic 
problems  surrounding  prostitution  are  necessarily  intricate.  Man  and 
woman  hold  entirely  different  positions  in  regard  to  it.  The  man  who 
transgresses  has  but  little  thought,  other  than  perhaps  a  preliminary 
burning  of  conscience,  of  the  moral  side  of  the  transgTCSsion.  His  one 
thought  is  to  seek  consultation  in  order  to  rid  himself  of  the  disease,  and 
when  cured  he  is  no  better  nor  worse  than  the  small  percentage  of  his 
follows  who  have  not  transgressed.     He  belongs  to  the  majority. 

On  the  other  hand,  the  woman  who  transgresses  is  an  outcast.  Her 
3ne  thought  is  neither  to  seek  advice  nor  consultation,  but  to  hide  every- 
tliinc:. 

The  causes  for  these  two  points  of  view  are  probably  on  the  one 
hand  man's  aggressive  nature,  his  ability  to  create  public  opinion,  and 

137 


138  GONORRHEA  IN  WOMEN 

on  the  other  hand  woman's  passive  acquiescence  to  these  created 
standards. 

It  is  this  man  who  has  transgressed,  who  has  had  experience,  who 
marries.  Therefore,  when  any  question  of  gonorrheal  infection  comes 
up  after  marriage  his  experience  is  pitted  against  his  wife's  ignorance 
in  disguising  the  real  condition  of  affairs.  And  if  strange  and  over- 
whelming disease  comes  to  the  woman  after  marriage,  not  realizing  what 
causes  might  be  responsible,  she  has  been  taught  to  believe  that  this 
suffering  is  woman's  portion  and  has  accepted  her  lot.  That  woman  is 
monogamous  by  instinct  has  not  a  little  to  do  with  this  point  of  view. 

ISTot  so  with  the  man ;  if  he  has  reason  to  believe  he  may  have  gon- 
orrhea, at  the  outset  of  the  first  symptoms  he  consults  a  physician  and 
the  physician  must  be  ready  with  prompt  and  efficacious  treatment  if  he 
would  hold  this  patient.  Out  of  this  situation  have  arisen  numerous 
methods  or  schools  of  treating  acute  gonorrhea  in  the  male,  and  this 
treatment  has  reached  a  stage  of  great  perfection,  because  the  demand 
for  such  treatment  has  been  insistent. 

With  his  female  patients  the  physician  has  been  put  under  no  such 
pressure  for  diagnosis,  and  while  he  has  achieved  lasting  fame  in  the 
treatment  of  the  later  surgical  complications  of  gonorrhea  in  the  female, 
he  has  often  gone  in  the  line  of  least  resistance  in  making  a  diagnosis  of 
gonorrhea  in  its  early  stages.  The  woman,  not  suspecting  what  may  be 
at  the  bottom  of  her  slight  indisposition,  has  too  often  been  reassured 
by  the  statement,  "Oh,  the  discharge  is  only  the  result  of  marriage  re- 
lations." "You  have  taken  a  slight  cold  in  your  bladder,"  etc.  She 
goes  home  and  neglects  herself,  and  returns  to  her  physician  only  when 
symptoms  have  sufficiently  asserted  themselves  so  that  he  can  make  a 
clinical  diagnosis  of  gonorrhea.  As  a  result  many  a  case  of  acute  gon- 
orrhea in  the  female  is  grossly  mishandled  and  swells  the  lists  of  those 
cases  later  demanding  surgical  skill. 

When,  therefore,  the  possible  gonorrheic  presents  herself  for  consul- 
tation, the  conscientious  examiner  must  tactfully  approach  his  task  and 
attempt  to  find  out  in  which  one  of  the  following  classifications  this  par- 
ticular woman  belongs. 

First :  Is  she  a  married  woman  who  has  innocently  contracted  the 
disease,  knowing  nothing  of  its  nature  ?  If  so,  the  economic  question  of 
not  destroying  the  marriage  relation  presents  itself. 

Second :  Is  she  an  unmarried  woman  who  has  contracted  the  disease 
as  a  result  of  illicit  intercourse  ?  If  so,  is  she  a  "first  offender,"  un- 
aware of  the  enormity  of  what  she  has  done,  or  is  she  a  prostitute  ? 

Third:  Is  she  an  unmarried  woman  who  is  quite  innocent  of  any 
sexual  relations,  and  has  had  the  misfortune  to  contract  the  disease  by 
the  use  of  infected  linen,  toilets,  douche  outfits,  or  dirty  instrumenta- 
tion? 


ETIOLOGY  AND  PATHOLOGY  139 

Fourth :  Is  she  perhaps  one  of  the  victims  of  a  former  infant  gon- 
orrhea ? 

Fifth :  If  the  patient  be  a  little  girl,  has  she  become  infected  from 
some  unrecognized  source  in  her  own  family  ? 

The  importance  of  a  correct  diagnosis  at  once  becomes  apparent : 

1.  For  the  safety  of  the  family  or  community.  If  the  innocent 
woman  is  infected  she  must  be  instructed  how  to  take  care  of  herself,  as 
she  may  infect  other  members  of  her  family  or  her  own  eyes.  If  the 
patient  be  a  prostitute,  she  must  be  warned  that  she  is  in  an  infectious 
state. 

2.  In  justice  to  the  individual.  It  is  only  necessary  to  mention  how 
important  it  is  to  know  ichat  germ  is  responsible  for  the  infection.  It 
may  mean  the  ruin  of  an  innocent  woman's  life  to  be  labeled  gonorrheic 
when  an  entirely  different  cause  could  be  found  on  investigation. 

3.  For  the  purpose  of  intelligent  treatment  and  prognosis. 

ETIOLOGY  AND  PATHOLOGY 

The  various  clinical  manifestations  of  gonorrhea  in  the  female  vary 
in  accordance  with  the  following  conditions : 

1.  The  viruleiice  of  the  infecting  gonococcus. 

2.  The  resistance  of  the  tissues  which  are  invaded, 

3.  Whether  the  original  infection  is  a  mixed  infection;  i.e.,  the 
pyogenic  organisms  are  present  as  well  as  the  gonococcus. 

4.  The  raising  of  the  virulence  of  the  original  infection  by  certain 
processes  in  the  woman.  (This  accounts  for  many  cases  of  so-called 
"one-child  sterility.") 

Doderlein  ^  says : 

"Clinical  exiierienoe  and  bacteriological  investigations  have  given  rise  to  the 
following  important  conclusions  respecting  the  etiology  and  pathology  of  gonor- 
rhea: 

''A  wide  jyatulous  external  urethral  orifice  in  the  male  favors  the  entrance  of 
the  female  secretion;  so  that  one  with  such  a  urethral  orifice  may  acquire  gonor- 
rhea, while  another — later  comer — may  not  acquire  it. 

"Likewise  in  the  female  the  anatomical  conformation  of  the  genitalia  has  an 
influence  on  the  kind  of  gonorrheal  infection;  with  a  narrow  vaginal  outlet,  vir^ 
ginal,  the  urethra  is  likely  to  become  infected;  and  in  a  non-virginal  vagina  the 
infecting  agent  more  easily  comes  in  contact  with  the  upper  part  of  the  vagina 
and  cervix.  Infection  ivith  acute  gonorrheal  pus  causes  in  women  a  much  more 
acute,  stormy  attack  of  ascending  gonorrhea  (Wertheim)  than  an  infection  with 
chronic,  latent  gonorrhea. 

"In  labor  the  gonococci  in  the  lochia  become  more  virulent,  which  favors  an 
ascending  infection. 

"In  marriage  the  two  participants  may  become  immune  to  each  other's  gono- 

^  Kiistner,  Lchrbuch  der  Gyndkologie,  1904,  p.  389. 


140  GONORRHEA  IN  WOMEN 

cocci.  So  that  it  is  not  possible  to  have  a  further  exacerbation  of  gonorrhea 
between  these  two.  When  a  third  person  trespasses^  however,  it  is  possible  that 
he  may  have  an  attack  of  acute  gonorrhea,  while  neither  the  man  nor  woman  have 
any  manifest  gonorrhea  {Wertheim).  Not  every  connection  with  a  gonorrheic 
woman  is  followed  by  an  infection,  because  in  chronic  gonorrhea  the  genital 
secretions  can  at  times  be  free  of  gonococci.  Marked  irritation  of  the  genitals, 
menstrual  or  puerperal  secretions  bring  the  gonococcus  to  the  surface,  and  so 
raise  the  infectiousness  of  the  woman.  Under  these  conditions  the  symptomless 
gonorrhea  of  man  can  experience  a  recrudescence,  and  the  man  can  through  his 
wife  be  infected  with  a  virulent  gonorrhea. 

"In  man,  latent,  i.  e.,  symptomless  yet  infectious  gonorrhea  can,  through  ex- 
cesses, especially  those  venereal  {marriage),  experience  exacerbations  and  appear 
after  a  pause  of  perhaps  ten  or  twenty  years." 

I  absolutely  disbelieve  this. 

The  organs  covered  by  pavement  epithelium  are  more  resistant  to 
the  gonococcus  than  those  covered  by  cylindrical  epithelium,  and  the 
organs  therefore  most  frequently  involved  in  the  order  of  frequency  are 
the  urethra,  cervix  uteri,  posterior  vaginal  vault  (where  the  infected 
cervix  comes  in  contact  with  the  vaginal  wall),  the  vulva,  and  the  re- 
maining portions  of  the  vagina. 

There  are  further  certain  spots  of  predilection  where  the  gonorrheal 
infection  is  apt  to  settle  and  become  chronic,  i.e.,  Skene's  glands  and 
Bartholin's  glands.  At  the  opening  of  the  ducts  leading  from  Bartho- 
lin's glands  two  small  reddened  spots  can  be  seen  when  the  ducts  are  in- 
fected with  gonorrhea.  These  spots  are  called  the  "maculae  gonor- 
rhoicae"  (of  Sanger^). 


THE  HISTORY  OF  THE  CASE 

By  inquiring  carefully  into  the  history  of  a  given  case  and  the  prob- 
able mode  of  infection  much  valuable  assistance  can  often  be  gained. 

Thus,  if  no  history  of  sexual  intercourse  is  obtained  and  it  is  found 
that  the  patient  has  been  using  toilet  articles,  towels,  etc.,  which  might 
be  a  source  of  infection,  the  inference  may  be  made  that  the  infection 
is  chiefly  external  around  the  vulva,  urethra,  and  vaginal  outlet. 

Again,  as  sometimes  occurs  in  dispensary  practice,  if  a  history  is 
given  of  attempted  intercourse  (rape)  in  which  the  act  was  not  accom- 
plished, a  similar  observation  may  be  made. 

Also  in  newly  married  women  a  history  of  incomplete  intercourse 
may  be  obtained,  and  especially  in  cases  where  precautionary  measures 
against  conception  are  used,  as  withdrawal  or  the  use  of  protectors,  one 
may  again  expect  to  find  a  low  infection  around  the  vulva  or  vaginal 
outlet. 

^Centrlbl.  f.  Gyn.,  1896,  p.  1073. 


SYMPTOMS  141 


SYMPTOMS 


The  patient  usually  complains  of  a  profuse  burning  discharge  and 
difficult  burning  micturition. 

These  two  symptoms  in  a  woman  who  has  previously  been  well  sug- 
gest at  once  a  possible  gonorrheal  involvement,  the  more  so  if  coupled 
with  a  history  of  any  of  the  above  mentioned  modes  of  infection. 

Other  subjective  symptoms  may  be  given,  as,  for  instance,  pain  when 
walking  or  sitting,  sense  of  fullness  and  weight  in  the  groins,  small  of 
back,  or  at  the  vaginal  outlet,  or  occasionally  the  patient  may  report  a 
bloody  urine  if  the  bladder  involvement  is  marked. 

An  examination  of  the  affected  parts  will  give  the  further  objective 
symptoms  necessary  to  make  the  diagnosis.  The  details  of  the  first 
examination  will  vary  directly  with  the  history  obtained,  and  the  viru- 
lence of  the  infection  as  observed  when  the  vulva  is  inspected. 

If  the  history  of  a  probable  low  infection  has  been  obtained,  and  an 
acute  condition  of  the  vulva  and  urethral  opening  is  found,  a  smear  of 
the  discharge  should  be  taken  by  means  of  a  sterile  platinum  loop  for 
examination  and  no  further  examination  made  until  the  acute  external 
inflammation  has  subsided.  The  patient  should  be  kept  in  bed  {see 
Acute  Urethritis). 

If  the  patient  gives  a  history  of  a  probable  high  infection  and  com- 
plains of  pain  in  the  region  of  uterus  or  tubes,  and  this  is  verified  by 
abdominal  palpation,  a  careful  bimanual  examination  should  be  made 
at  once,  for  the  case  may  call  for  immediate  surgical  care. 

Should  the  patient  come  with  the  history  of  a  subacute  or  chronic 
infection,  the  following  routine  examination  should  be  made :  the  pa- 
tient should '  be  instructed  not  to  take  a  douche  before  submitting  to 
the  examination.  In  this  way  the  characteristics  of  the  discharge  can 
be  noted. 

The  vulva  should  be  inspected  carefully ;  oftentimes  venereal  warts 
are  found  around  the  anus  or  vaginal  outlet.  The  labia  majora  should 
be  spread  apart  and  search  made  for  the  maculae  gonorrhoicae  at  the 
openings  of  Bartholin's  glands.  By  slipping  the  index  finger  into  the 
vagina  for  about  one-half  inch  and  placing  the  thumb  over  the  macula, 
oftentimes  an  induration  or  abscess  of  Bartholin's  glands  can  be  pal- 
pated. Should  any  pus  exude  from  the  ducts  a  smear  and  culture 
should  be  made  and  laid  aside  for  examination.  Examination  of  the 
urethral  orifice  should  next  be  made.  If  a  free  discharge  of  pus  be 
found  in  the  urethra,  a  smear  and  culture  should  be  taken,  and  then  the 
urethral  orifice  carefully  wiped  off',  and  an  examination  made  of  Skene's 
glands.  Again,  by  passing  the  index  finger  into  the  vagina  and  running 
it  up  toward  the  bladder  end  of  the  urethra  and  then  massaging  the 


142  GONORRHEA  IN  WOMEN 

"urethra  toward  its  outer  end,  a  tiny  drop  of  pus  can  oftentimes  be 
expressed  for  a  smear  and  culture. 

The  vaginal  outlet  should  next  be  inspected,  and  if  a  discharge  is 
found  to  be  coming  down  from  above,  a  further  examination  should  be 
made  with  a  speculum. 

When  the  examination  is  made,  gTeat  care  should  be  taken  to  cleanse 
the  vaginal  outlet  of  all  discharge,  so  that  no  infection  be  mechanically 
carried  from  outside  upward  to  the  cervix. 

When  the  cervix  is  well  exposed  by  the  speculum  specimens  should 
be  taken  from  the  discharge  found  around  the  external  os.  The  cervix 
is  carefully  inspected  and  then  the  posterior  vault  of  the  vagina  for  any 
erosions  of  the  mucous  membrane  produced  by  contact  with  the  infected 
cervix. 

After  the  speculum  examination  is  completed,  a  careful  bimanual 
palpation  should  be  made.  With  reference  to  the  condition  of  the  uterus 
and  adnexa,  special  note  should  be  made  as  to  the  size,  position,  mobil- 
ity, and  sensitiveness  of  the  uterus ;  as  to  whether  the  tubes  are  enlarged 
or  tender  and  as  to  whether  perimetrium  or  parametrium  is  involved. 
If  an  advanced  or  urgent  condition  of  the  pelvic  organs  be  found, 
the  case  may  have  already  passed  over  into  the  domain  of  surgical 
gynecology. 

VARIETIES 

ACUTE  URETHRITIS 

Urethritis  is  considered  the  most  frequent  form  of  gonorrheal  infec- 
tion of  the  female  genitalia.  This  is  probably  due  to  the  fact  that  in  the 
beginning  of  the  sexual  act  the  labia  majora  are  pushed  apart  by  the 
glans  penis,  and  the  urethral  orifice  in  this  way  is  put  on  the  stretch. 
The  ducts  of  Skene's  glands,  lying  inside  of  the  urethral  orifice,  are  then 
brought  in  direct  contact  with  the  infecting  discharge  from  the  male 
urethra,  as  is  the  lining  epithelium  of  the  female  urethra.  And  as  this 
epithelium  is  columnar,  the  infection  readily  takes  place. 

Symptoms. — The  patient  usually  complains  of  an  intense  burning 
discharge  at  the  urethra  and  a  sense  of  burning  or  "sticking"  pain  on 
micturition.  Sometimes  there  is  a  marked  tenesmus  or  even  retention 
if  the  patient  is  nervous.  She  may  note  that  she  passes  a  few  drops  of 
blood  at  the  end  of  urination. 

Examination  generally  shows  an  intensely  reddened  urethral  open- 
ing, oftentimes  with  the  swollen  mucosa  bulging  out  of  the  orifice,  giving 
the  appearance  of  a  prolapse.  Pus  is  seen  oozing  down  over  the  mucosa. 
The  orifices  of  Skene's  glands  may  be  conspicuous  or  they  may  not  be 
demarcated  from  the  rest  of  the  violently  congested  mucosa. 

Palpation  of  the  urethra  per  vaginam  (care  being  taken  to  carry 


VARIETIES  143 

none  of  the  pus  up  with  the  examining  finger)  gives  acute  tenderness. 
Oftentimes  the  urethra  feels  like  a  cord  under  the  finger. 

Diagnosis — Diagnosis  is  not  difficult  if  a  careful  history  has  been 
elicited;  a  smear  taken  of  the  discharge  should  show  gonococci.  Ure- 
thritis following  infection  by  catheterization  can  usually  be  excluded  by 
the  history  and  the  absence  of  gonococci  in  the  smear.  Urethritis  caused 
by  the  irritation  of  concentrated  urine,  chemical  irritants,  traumatism, 
or  the  exanthematous  diseases  can  usually  readily  be  excluded  by  the 
history. 

Treatment. — Eest  in  bed  and  absolute  cleanliness  are  essential  in 
treating  acute  urethritis.  The  attendant  should  be  warned  of  the  in- 
fectiousness of  the  discharge  and  all  soiled  dressings  destroyed.  Three 
or  four  times  a  day  the  urethral  orifice  and  vulva  should  be  gently 
flushed  off  with  copious  hot  irrigations  of  boracic  acid  solution  or  bi- 
chlorid  of  mercury  1:  6,000  or  lysol  {^  to  1  per  cent).  These  irriga- 
tions can  be  given  by  means  of  a  fountain  syringe  with  the  patient  in 
the  dorsal  position  on  a  douche  pan.  After  the  irrigation,  the  vulva 
should  be  covered  with  an  absorbent  pad.  The  diet  at  first  should  be 
mainly  liquids — milk,  broths,  and  nonirritating  foods.  Condiments 
and  alcohol  in  any  form  should  be  absolutely  forbidden. 

The  patient  should  be  encouraged  to  drink  large  quantities  of 
water. 

If  the  irritability  and  tenesmus  is  marked,  a  urinary  sedative  should 
be  administered  (p.  220)  : 

As  the  most  acute  symptoms  subside  local  applications  should  be 
made  to  the  urethral  opening  after  the  irrigation  has  been  used.  Two 
to  four  per  cent  protargol  freely  applied  by  means  of  a  swab,  around 
the  urethral  mouth  and  openings  of  Skene's  glands  may  be  very  help- 
ful. Argyrol  (10  to  25  per  cent)  can  also  be  used.  These  applications 
can  be  made  once  or  twice  a  day.  A  certain  number  of  these  cases 
respond  promptly  to  treatment,  and  make  an  excellent  recovery ;  but, 
unfortunately,  many  pass  into  the  subacute  or  chronic  state. 

As  many  cases  of  acute  urethritis  are  combined  with  cystitis,  it 
is  often  necessary  at  the  outset  to  start  bladder  irrigations  {see  Acute 
Cystitis). 

CHBONIC    URETHRITIS 

Usually  a  history  of  an  acute  attack  is  obtained,  but  occasionally  the 
patient  becomes  aware  of  her  condition  only  when  it  is  subacute  or 
chronic.  The  urethra  may  alone  be  involved  or  there  may  be  an  accom- 
panying cervicitis  or  cystitis.  The  discharge  in  these  cases  shows  as  a 
rule  pus  and  epithelium  cells  and  pyogenic  organisms,  the  gonococcus 
often  being  found  with  difficulty. 


144  GONORRHEA  IN  WOMEN 

Symptoms. — Frequency  of  urination  is  the  symptom  most  often 
found.  This  frequency  occurs  during  the  day  when  the  patient  is  in 
the  upright  position,  and  may  also  be  complained  of  at  night. 

In  milder  cases  the  patient  complains  of  an  occasional  "tickling" 
or  "burning"  on  urination,  and  this  may  be  very  intermittent  in  char- 
acter. 

Examination — By  massaging  the  urethra  through  the  vagina  a  thick 
mucopurulent  secretion  can  be  obtained.  This,  when  examined  micro- 
scopically, may  be  found  to  consist  of  epithelium  and  pus  cells  and  no 
gonococci  present.  The  urethra  in  these  chronic  cases  is  generally  found 
somewhat  indurated  and  tender  on  palpation.  After  the  urethra  has 
been  emptied  of  its  secretion  and  this  wiped  off,  a  more  thorough  mas- 
sage over  Skene's  glands  may  bring  a  tiny  drop  of  pus  to  each  duct. 
Oftentimes  the  gonococcus  will  be  found  here  when  it  has  disappeared 
from  the  urethral  discharge  proper. 

It  may  be  of  value  to  ascertain  whether  the  anterior  or  posterior  por- 
tion of  the  urethra  is  chiefly  involved.  By  massaging  first  the  anterior 
portion  and  later  the  posterior  a  rough  estimate  of  the  involvement  can 
be  obtained.  Examination  by  the  endoscope  may  show  local  areas  of 
congestion  and  erosion  in  the  course  of  the  urethra. 

Treatment. — The  general  treatment  is  the  continuance  of  a  simple 
diet  without  the  use  of  condiments  or  alcohol.  The  internal  drugs  com- 
monly used  are  the  same  as  prescribed  for  male  patients  {see  p.  218). 

Local  treatment  is  accomplished  by  the  application  of  the  various 
silver  salts  to  the  urethral  mucosa.  This  can  be  done  by  means  of  a  glass 
medicine  dropper  or  by  bladder  irrigations  (p.  207). 

These  treatments  should  be  given  three  times  a  week,  later  twice  a 
week.  If  localized  erosions  are  discovered  these  should  be  touched  up 
with  silver  nitrate  (5  per  cent)  with  the  aid  of  the  endoscope. 

If  this  process  is  painful,  it  may  be  necessary  to  first  anesthetize  the 
urethra.  This  can  readily  be  done  by  inserting  a  fine  applicator  wound 
with  cotton  dipped  in  alypin,  5  per  cent. 

In  certain  resistant  cases  the  application  of  urethral  pencils  is  very 
useful.  These  are  variously  prepared,  containing  various  medicaments, 
as  silver  nitrate,  protargol,  argyrol,  ichthargen,  or  astringents  such  as 
zinc  sulphate.  Astringents  are  of  great  value  in  the  later  stages  of 
urethritis. 

These  pencils  have  the  double  value  of  acting  mechanically  as  a 
small  sound  to  dilate  the  urethra.  They  should  be  lubricated  with  a 
sterile  lubricant  before  inserting. 

Complications. — If  persistent  involvement  of  Skene's  glands  con- 
tinues long  after  the  urethritis  has  been  controlled,  it  may  be  necessary 
to  split  open  these  little  glands ;  this  can  be  done  by  means  of  a  fine  scis- 
sors under  local  anesthesia ;  the  glands  and  duct  should  then  be  swabbed 


VARIETIES  145 

out  with  carbolic  acid  (95  per  cent),  followed  by  alcohol,  or  with  a 
strong'  30  to  50  per  cent  silver  nitrate  or  silver  stick. 

Caruncles  may  form  in  the  irritated  and  hypertrophied  mucous 
membrane  around  Skene's  glands. 

Stricture  of  the  urethra  is  relatively  rare  in  women  and  should  be 
treated  by  dilating  with  a  female  urethral  sound.  Care  should  be  taken 
that  the  dilatation  is  not  too  great,  as  the  urethral  wall  may  easily  be 
injured.     Dilatation  up  to  28  to  30  F.  is  suflScient. 

CYSTITIS 

Gonorrheal  cystitis  or  cystitis  arising  from  catheterization  (e.  g.,  in 
postoperative  retention)  is  more  frequently  seen  in  women  than  in  men. 

Catheterization  should  in  all  cases  be  followed  by  an  antiseptic  irri- 
gation and  the  catheter  of  election  is  the  glass  one. 

The  symptoms,  diagnosis,  and  treatment  of  cystitis  are  discussed  in 
Chapter  XXXYIII. 

AC?UTE  CERVICITIS 

l^ext  to  the  urethra,  the  cervix  is  considered  the  organ  most  fre- 
quently infected  by  gonorrhea. 

There  are  two  reasons  for  this :  the  cer^'ical  mucosa  is  columnar 
in  type,  therefore  especially  prone  to  gonorrheal  infection ;  and  secondly, 
during  coitus  the  seminal  discharge  is  poured  directly  over  or  around 
the  cervix. 

In  a  large  percentage  of  cases  the  cervix  and  urethra  are  involved 
at  the  same  time ;  it  is  rare  to  see  a  gonorrheal  cervicitis  without  a  ure- 
thritis, but  the  reverse  is  not  true. 

Symptoms. — There  is  generally  a  sense  of  fullness  or  weight  in  the 
region  of  the  vagina  and  a  discharge.  If  the  body  of  the  uterus  is  in- 
volved there  may  be  considerable  pain  in  the  hypogastrium. 

Examination. — Examination  shows  the  cervix  much  reddened  and 
covered  with  more  or  less  purulent  discharge.  A  smear  usually  shows 
the  gonococcus.  On  wiping  away  the  discharge  the  mucous  membrane 
may  show  bleeding  points  or  erosions  and  the  cervix  may  appear  edem- 
atous. 

Diagnosis. — Diagnosis  must  be  made  from  the  ordinary  form  of 
cervicitis  such  as  is  found  with  a  laceration  of  the  cervix  due  to  child- 
birth; or  cervicitis  due  to  passive  congestion,  as  in  certain  displace- 
ments and  stenosis  of  the  cervix. 

Carcinoma  of  the  cervix  is  differentiated  by  the  examination  of  ex- 
cised portions  of  tissue  in  doubtful  cases. 

Involvement  of  the  mucous  membrane  in  any  of  the  exanthematous 
diseases  can  be  differentiated  by  the  presence  of  other  symptoms. 


146  GONORRHEA  IN  WOMEN 

Syphilitic  mucous  patches  can  also  be  excluded  by  the  history  and 
clinical  findings,  although  these  cases  are  sometimes  very  puzzling  and 
a  double  infection  may  be  found. 

The  same  is  true  of  chancres  and  chancroids.  The  finding  of  the 
Spirochaeta  pallida  or  the  bacillus  of  Ducrey  may  establish  the  diag- 
nosis. 

Treatment. — Some  physicians  are  averse  to  douching  in  the  most 
acute  stages  of  cervicitis,  as  they  claim  that  there  is  danger  of  negating 
the  value  of  the  acid  secretion  of  the  vagina  which  is  a  natural  safe- 
guard. 

If  the  cervix  is  actually  involved,  it  seems,  in  the  opinion  of  the 
writer,  better  judgTaent  to  keep  mechanically  removing  the  constantly 
accumulating  discharge  than  to  allow  it  to  remain  in  contact  with  both 
the  affected  and  unaffected  mvicous  surfaces. 

Therefore  copious  hot  irrigations  of  a  mild  antiseptic  solution  are 
advised,  under  low  pressure,  so  that  there  shall  be  no  driving  of  the  dis- 
charge farther  up  into  the  cervix. 

Boric  acid  solution  (2  per  cent),  lysol  (1  per  cent),  bichlorid  of 
mercury  (1:5,000  to  10,000),  permanganate  of  potassium  or  creolin 
(|-  per  cent)  are  used.  These  irrigations  should  be  given  two  or  three 
times  daily  or  oftener  if  the  discharge  is  very  profuse. 

CHRONIC  CERVICITIS 

This  may  follow  an  acute  attack,  or  the  onset  may  have  been  so 
chronic  in  character  that  the  patient  has  not  been  aware  of  its  existence. 
The  history  is  often  of  very  little  value,  and  the  diagnosis,  even  after 
a  most  careful  examination,  may  only  be  presumptive,  unless  per- 
haps some  complication  (as  salpingitis)  arises,  which  proves  the  diag- 
nosis. 

Gonococci  are  often  not  found  in  the  discharge,  this  discharge  being 
composed  only  of  pus  and  epithelial  cells. 

In  these  cases  an  examination  should  always  be  made  just  after  men- 
struation, as  the  mucosa  at  this  time  is  more  congested  and  the  des- 
quamation of  the  mucosa  favors  the  throwing  off  of  the  deeper  glandular 
secretions  and  the  gonococci  which  have  penetrated  to  these  deeper 
structures. 

The  fact  that  the  discharge  after  menstniation  may  be  more  infec- 
tious than  at  other  times  has  undoubtedly  given  rise  to  the  popular 
superstition  that  gonorrhea  may  be  contracted  from  intercourse  during 
the  menstrual  period. 

Symptoms. — The  usual  symptom  is  a  discharge.  This  may  be  very 
slight  and  be  practically  the  only  symptom,  or  painful  urination  may  be 
found  if  urethritis  is  present  also.     There  may  be  disturbances  of  men- 


VARIETIES  147 

struation  if  the  endometrium  is  involved.     Again,  sterility  may  be  the 
only  complaint. 

Examination  usually  shows  a  coexisting  urethritis  with  involvement 
of  Skene's  glands  and  the  maculae  gouorrhoicae.  However,  occasionally 
these  are  all  absent  and  the  one  pathological  condition  found  is  around 
the  cervix.  Here  the  mucosa  may  be  somewhat  reddened  and  a  dis- 
charge varying  in  type  be  found.  It  -may  be  thin  and  watery  or  thick 
and  purulent — yellowish  or  green  in  color.  There  may  be  slight  ever- 
sion  of  the  cervical  mucous  membrane  through  the  external  os,  and 
erosions  which  bleed  more  or  less  easily  may  be  found  on  the  cervical  or 
posterior  vaginal  mucosa.  The  cervix  may  appear  swollen  and  boggy 
and  tiny  varicose  vessels  may  be  seen  around  the  os. 

Diagnosis. — If  erosions  are  present  on  the  cervix,  even  if  the  gono- 
coccus  be  absent,  a  diagnosis  can  be  made  by  the  complement  fixation 
test. 

Treatment. — Local  applications  to  the  cervix  are  especially  indi- 
cated. The  cervix  should  be  brought  into  view  by  means  of  a  bivalve 
speculum  and  then  carefully  examined.  If  erosions  are  present  they 
should  be  wiped  off  with  sterile  cotton  and  then  touched  up  with  silver 
nitrate  (10  per  cent),  Churchill's  tincture  of  iodin,  or  plain  tincture 
of  iodin.  Care  should  be  taken  not  to  carry  any  instrument  up  through 
the  internal  os,  as  in  this  way  the  endometrium  may  be  infected.  It  is 
often  advantageous  to  immerse  the  entire  cervix  in  a  solution  so  as  to 
reach  all  the  parts  involved. 

The  Ferguson  speculum  is  useful  for  this  and  it  should  be  inserted 
until  the  cervix  is  in  view,  the  solution  poured  in,  and  the  speculum 
partially  withdrawn.  By  so  doing  the  cervix  is  dipped  into  a  pool  of 
solution  and  allowed  to  remain  there  for  a  number  of  minutes  (five  to 
ten  minutes),  and  then  the  speculum  is  pushed  into  the  original  depth 
and  depressed,  when  the  fluid  is  easily  drained  out. 

Silver  solutions  most  frequently  used  are  silver  nitrate  3  to  5  per 
cent,  protargol  2  to  10  per  cent,  argyrol  10  to  25  per  cent. 

In  some  cases,  where  the  tissue  seems  boggy  and  congested  and  the 
inflammatory  condition  is  not  so  marked,  instillation  of  zinc  salts  in  the 
manner  described  above  is  useful. 

After  the  cervix  has  been  treated  in  one  of  the  above-mentioned 
ways,  a  tampon  of  boroglycerin  (10  per  cent),  or  ichthyol  and  glycerin 
(10  per  cent)  may  be  used;  or  a  dry  tampon  sprinkled  with  aristol, 
dermatol,  or  iodoform  may  be  placed  against  the  cervix. 

In  cases  where  the  discharge  from  the  cervix  is  very  profuse  it 
is  better  not  to  use  tampons  at  flrst,  as  they  may  dam  back  the  dis- 
charge against  the  cervix.  In  the  presence  of  a  vulvitis  it  may  be 
necessary  to  tampon,  and  if  so  special  precautions  should  be  taken  (see 
p.  151). 


148  GONORRHEA  IN  WOMEN 

In  chronic  cervicitis  tlie  above  treatment  should  be  given  in  the  of- 
fice, at  first  three  times  a  week  and  gradually  reducing  the  frequency  of 
treatment  as  the  symptoms  improve. 

Douches  should  be  ordered  as  home  treatment,  at  first  once  or  twice 
a  day  and  later  two  or  three  times  a  week.  In  some  cases  the  treatment 
may  be  hastened  by  the  home  use  of  suppositories  containing  various 
medicaments,  ichthyol,  protargol,  zinc,  etc.  These  can  be  inserted  by 
the  patient  every  other  night  or  less  often.  The  solutions  for  douching 
should  be  mild  antiseptics  or  astringents  as  used  in  the  office. 

ACUTE  VAGINITIS 

The  vagina  in  the  adult  is  one  of  the  most  resistant  parts  of  the  geni- 
tal tract,  as  it  is  covered  with  pavement  epithelium ;  and  -  further, 
through  the  trauma  occasioned  by  intercourse  and  childbirth,  it  becomes 
to  a  certain  degree  toughened  and  not  easily  infected.  But  the  vaginal 
membrane  readily  becomes  involved  in  young  girls,  whose  mucosa  is 
delicate,  or  in  newly  married  women,  whose  mucosa  is  not  hardened 
by  congestion  and  trauma. 

When  the  gonorrheal  infection  is  hyperacute  the  entire  genital 
tract  may  be  involved  in  one  continuous  infection,  and  in  these  cases 
the  vagina  is  not  exempt. 

Acute  vaginitis  may  be  primary,  but  is  usually  secondary  to  a  gon- 
orrheal cervicitis  or  endometritis. 

Symptoms. — The  patient  complains  of  burning  and  a  sense  of  weight 
in  the  vagina,  and  as  the  vaginitis  is  usually  accompanied  by  urethritis 
and  cervicitis,  the  symptoms  of  these  conditions  are  usually  added. 
Examination  with  a  speculum  in  the  knee-chest  position  (observing 
the  precautions,  p.  142)  shows  the  vaginal  mucosa  to  be  the  seat  of 
an  acute  inflammatory  process.  The  entire  vaginal  wall  may  be  in- 
tensely congested,  hot,  swollen,  and  bleeding  readily,  or  it  may  be 
bathed  in  a  copious  purulent  discharge.  Erosions  with  bleeding  edges 
may  be  found,  usually  in  the  posterior  fornix  or  in  other  portions  of 
the  vagina.  The  gonococcus  can,  as  a  rule,  be  readily  found  in  the 
discharge. 

Diagnosis. — Acute,  nongonorrheal  traumatic  vaginitis  is  encoun- 
tered in  the  newly  married  and  among  those  who  use  strong  medicated 
douches  as  a  precautionary  measure.  These  forms  of  vaginitis,  puzzling 
at  first,  can  usually  be  very  easily  differentiated  by  the  absence  of 
gonococci  in  the  discharge  and  the  almost  immediate  response  to  treat- 
ment when  the  cause  is  removed. 

Other  forms  of  vaginitis  (due  to  the  exanthemata,  cervical  car- 
cinoma, or  simple  cervicitis)  can  be  eliminated  by  the  history  and  find- 
ings in  each  case  and  the  absence  of  gonococci. 


CHRONIC  VAGINITIS  149 

Treatment.- — Eest  in  bed  and  frequent  douches  of  mild  antiseptic 
solutions  should  be  ordered.  In  the  most  acute  stages,  when  the  pain  is 
severe,  boracic  acid  douches,  at  a  temperature  of  100°  to  110°  F.,  under 
mild  pressure,  are  probably  the  most  beneficial  and  soothing.  These 
should  be  given  frequently,  every  two  or  three  hours,  if  the  discharge  is 
profuse,  and  the  utmost  care  should  be  taken  in  regard  to  asepsis. 

If,  at  the  time  of  the  examination,  the  lower  portion  of  the  vagina  is 
found  to  be  the  part  especially  involved,  care  should  be  taken  to  insert 
the  douche  tip  but  1  to  2  inches  into  the  vagina  and  flush  out  only 
the  lower  portion. 

After  the  early  acute  stage  is  over,  lysol  or  bichlorid  of  mercury 
(1 :  15,000  to  10,000)  can  be  substituted,  and  gradually  a  daily  or  twice 
daily  instillation  of  protargol  (4  to  10  per  cent)  or  argyrol  (25  per 
cent)  can  be  made  with  a  glass  syringe,  the  douche  preceding  this 
treatment. 

Douches  should  be  given  sufficiently  often  to  keep  the  vaginal  outlet 
quite  clean  and  thus  preventing  a  secondary  vulvitis.  Between  treat- 
ments absorbent  vulva  pads  should  be  worn  and  these  changed  often 
enough  to  insure  perfect  cleanliness. 


CHRONIC  VAGINITIS 

Usually  a  history  of  a  previous  gonorrheal  infection  is  obtained. 
Primary  chronic  gonorrheal  vaginitis  is  rare,  for  the  vagina,  on  account 
of  its  resistance,  is  about  the  last  structure  in  the  female  pelvic  organs 
to  become  involved,  and  when  it  does  become  the  seat  of  a  chronic 
gonorrhea,  usually  a  profound  gonorrheal  infection  has  occurred  else- 
where. 

Gonococci  may  have  entirely  disappeared  from  the  vaginal  dis- 
charge, which  may  consist  of  pus  and  epithelial  cells  alone. 

Symptoms. — The  only  symptom  complained  of  may  be  a  slight  leu- 
korrhea,  or  the  patient  may  have  more  or  less  pain  in  the  vagina  when 
walking  or  moving  about.  On  examination  with  a  speculum  in  the  knee- 
chest  position,  the  vaginal  mucosa  may  be  found  covered  with  a  purulent 
or  mucopurulent  discharge.  Localized  areas  of  erosion  are  usually 
present,  and  their  presence  keeps  up  the  leukorrhea  in  part. 

Diagnosis. — Diagnosis  usually  requires  the  complement  fixation  test, 
as  the  gonococci  have  often  entirely  disappeared. 

Treatment — The  treatment  is  in  the  main  the  same  as  for  acute 
vaginitis  (which  see)  ;  in  these  chronic  cases,  however,  the  process  is 
often  very  resistant  to  treatment.  The  erosions  should  be  touched  up 
with  silver  nitrate  10  per  cent,  or,  in  some  cases,  the  silver  stick  or  pure 
carbolic  acid,  followed  by  alcohol.     Tamponage  with  boroglycerin  or 


150  GONORRHEA  IN  WOMEN 

ichthyol  and  glycerin  is  often  of  great  assistance,  as  is  also  the  use  of 
medicated  suppositories.  In  certain  cases  the  use  of  brewers'  yeast  is 
helpful.  Again,  a  change  of  treatment  to  dry  tampons  covered  with 
aristol  or  iodoform  may  bring  about  the  desired  results. 


ACUTE  VULVITIS 

In  the  adult  gonorrheal  vulvitis  is  found  much  less  frequently  than 
in  the  child  or  young  woman.  The  squamous  epithelium  of  the  vulva  is 
more  resistant  in  the  adult  than  the  child  and  the  trauma  of  childbirth 
and  marital  relations  make  it  more  so. 

Symptoms. — However,  an  acute  vulvitis  may  occur  and  give  very 
distressing  symptoms ;  the  chief  of  these  are  intense  burning  pain,  worse 
on  urination,  a  sensp  of  fullness  and  weight,  and  extreme  discomfort  in 
the  sitting  posture  or  on  walking. 

Examination  of  the  vulva  in  these  cases  usually  shows  the  entire 
vulva  to  be  the  seat  of  an  acute  inflammatory  process.  The  labia  may  be 
much  swollen  and  edematous,  and  their  inner  surfaces  bathed  in  a  copi- 
ous purulent  discharge.  On  separating  the  labia  excoriations  of  the 
mucosa  may  be  found  and  the  intensely  inflamed  surface  may  bleed 
easily. 

Further  examination  of  the  vagina  and  cervix  should  be  made  with 
the  precautions  stated  above,  for  occasionally  the  vulvitis  may  be  pri- 
mary, though  more  usually  a  urethritis  and  cervicitis  also  exist. 

Diagnosis — There  are  several  conditions  from  which  gonorrheal 
vulvitis  must  be  differentiated. 

Simple  vulvitis,  due  to  lack  of  cleanliness;  this  is  often  found  in 
obese  women,  especially  in  hot  weather  and  where  there  is  intertrigo. 
The  absence  of  the  gonococcus  in  the  smear  from  such  a  case  and  its 
prompt  reaction  to  treatment  will  easily  differentiate  this  form. 

Diabetes  often  gives  rise  to  a  violent  vulvitis,  due  to  the  decomposi- 
tion of  the  diabetic  urine  by  the  presence  of  the  torula  saccharomyces. 
The  age  of  the  patient  and  presence  of  sugar  in  the  urine  usually  elim- 
inate this  form  without  difficulty. 

Vulvitis  due  to  a  vesicovaginal'  fistula  can  be  differentiated  by  the 
history  and  the  finding  of  the  fistula. 

Vulvitis  due  to  a  discharge  pouring  down  from  a  nongonorrheal 
cervicitis  or  vaginitis  may  also  be  very  puzzling  until  the  discharge  is 
traced  back  to  its  origin  and  a  bacterial  examination  made. 

Vulvitis  due  to  the  excoriating  effect  of  the  discharge  from  a  car- 
cinoma of  the  cervix  or  vagina  may  also  simulate  acute  gonorrhea  in  its 
intensity. 

Vulvitis  complicating  any  of  the  exantJiemaious  diseases  can  be  dif- 
ferentiated by  the  history. 


CHRONIC  VAGINITIS  151 

Treatment. — -Primary  gonorrheal  vulvitis  should  be  treated  by  rest 
in  bed  and  absolute  cleanliness.  In  the  acute  stage  the  vulva  should  be 
irrigated  every  two  or  three  hours  (if  the  discharge  forms  rapidly) 
'with  a  warm  boracic  acid  solution  or  a  bichlorid  of  mercury  (1 :  6,000) 
or  lysol  (^  to  1  per  cent),  the  patient  being  in  the  dorsal  position  on  a 
douche  pan,  and  the  nurse  gently  separating  the  labia  so  that  the  irri- 
gation may  reach  the  internal  surfaces  of  the  labia  and  the  vaginal  and 
urethral  orifices.  After  the  irrigation  has  been  given,  a  pledget  of 
sterile  cotton  covered  with  sterile  vaselin  should  be  placed  lightly  be- 
tween the  opposed  infected  surfaces  to  keep  them  apart.  A  protargol 
ointment  (2  per  cent)  can  also  be  used  with  benefit. 

After  one  to  two  days  the  irrigations  may  be  given  less  often  and 
three  times  a  day  (after  an  irrigation)  the  vulva  may  be  painted  thor- 
oughly with  argyrol  (25  per  cent)  or  protargol  (4  per  cent). 

If  the  vulvitis  is  secondary  to  urethritis,  cervicitis  or  vaginitis,  the 
treatment  must  also  include  the  special  treatment  of  these  parts.  Often- 
times, when  a  vulvitis  is  secondary  to  a  cervicitis,  the  cure  of  the  vul- 
vitis can  be  much  hastened  by  sealing  off  the  cervix  from  the  vulva  by  a 
dry  tampon  of  sterile  cotton  after  the  cervix  has  been  duly  treated.  In 
these  cases  it  is  very  important  that  the  patient  be  kept  under  constant 
care,  as  these  tampons  must  never  be  left  in  long  enough  to  dam  back 
the  discharge  against  the  cervix  and  thus  delay  its  healing. 

CHRONIC  VULVITIS 

In  certain  cases  resistant  to  treatment,  or  in  cases  which  have  been 
neglected,  a  chronic  vulvitis  may  be  found. 

Symptoms. — Symptoms  are  discomfort  on  wallving  or  sitting  and 
more  or  less  discharge  on  the  vulva. 

Examination  may  show  certain  areas  of  localized  inflammation,  es- 
pecially around  the  glands  of  Bartholin,  which  glands  may  be  indurated 
or  the  seat  of  abscess. 

Diagnosis. — Chiefly  by  the  complement  fixation  test. 

Treatment.— If  the  vulvitis  is  primary  the  careful  and  persistent 
use  of  the  silver  salts  will  usually  cure  the  condition.  All  erosions 
should  be  touched  up  with  silver  nitrate  (10  per  cent)  and  the  remain- 
ing mucosa  painted  with  protargol  4  per  cent.  After  such  treatment 
it  may  be  well  to  dry  the  vulva  very  carefully  and  to  powder  it  with 
aristol  or  dermatol. 

Oftentimes  zinc  sulphate  (-|  per  cent)  will  uccouiplish  more  than 
the  silver  salts  and  should  be  used  alternately  if  results  from  the  fonner 
are  not  satisfactory. 

Suppuration  of  Bartholin's  glands  may  call  for  incision  and  drain- 
age, but  if  possible  it  is  best  to  dissect  out  the  infected  gland  as  a  whole, 


152  GONORRHEA  IN  WOMEN 

swabbing  out  the  cavity  with  bichlorid  of  mercury  (1 :  1,000)  and  pack- 
ing with  gauze. 


COURSE  AND   PROGNOSIS   OF   SYSTEMIC    GONORRHEAL   IN- 
FECTION IN  WOMEN 

Acute  gonorrhea  is  usually  seen  either  in  young  girls  or  in  the  pros- 
titute class,  and  is  characterized  by  the  usual  features  of  an  acute  in- 
fectious disease.  After  an  incubation  of  ten  to  fourteen  days  (which, 
however,  in  some  cases  is  as  rapid  as  twenty-four  hours)  the  patient  is 
seized  with  severe  constitutional  symptoms,  as  chill,  high  fever,  and 
rapid  pulse.  The  local  symptoms  are,  as  a  rule,  very  acute  and  may 
rapidly  invade  the  entire  genital  tract,  giving  rise  to  acute  endometritis, 
salpingitis,  and  peritonitis.  Metastatic  processes  are  not  uncommon  in 
these  cases,  as  involvement  of  the  joints,  endocardium,  and  even  men- 
inges. 

The  course  of  the  acute  infection  is  about  six  weeks,  after  which 
time  the  case,  with  careful  treatment,  may  recover  or  pass  into  a  sub- 
acute or  chronic  state.  The  majority  of  gonorrheal  infections  in  women 
are,  however,  from  the  start  subacute  or  chronic  in  type,  and  it  is  this 
larger  and  more  usual  class  which  is  the  more  difficult  of  diagnosis  and 
treatment.  The  onset  may  be  so  insidious  as  to  deserve  the  title  of  "la- 
tent gonorrhea."  These  cases  usually  present  a  very  typical  picture  if 
the  physician  is  on  the  alert  and  is  aware  of  this  form. 

Gonorrhea  is  essentially  an  infection  which  tends  to  remain  chronic 
rather  than  to  recover. 

Exacerbation  of  symptoms  after  apparent  cure  are  very  frequent. 
These  may  be  especially  noted  at  the  menstrual  period.  Again,  in  a 
case  supposedly  cured,  an  attack  of  grippe  or  any  indisposition  which 
affects  the  general  health  and  brings  it  below  par  may  start  an  acute 
exacerbation  of  symptoms. 

The  symptoms  thus  excited  are  usually  those  of  urethritis,  cystitis, 
or  cervicitis.  The  further  complications  of  endometritis  and  salpingitis 
are  especially  frequent  in  these  chronic  forms,  but  space  will  not  permit 
the  consideration  of  these  more  purely  gynecologic  conditions. 

Joint  involvement  may  occur  with  these  exacerbations,  and  in  cer- 
tain cases,  where  the  invasion  has  been  extensive  and  the  course  pro- 
tracted, the  patient  seems  to  lapse  into  an  almost  septic  state.  The 
picture  of  the  chronic  gonorrheic  is  pitiable  indeed.  There  is  usually 
loss  of  weight,  more  or  less  anemia,  general  lassitude,  and  mental  de- 
pression. She  is  the  victim  of  menstrual  disorders,  dysmenorrhea^  men- 
orrhagia,  and  a  chronic  leukorrhea. 

The  prognosis  of  a  given  case  depends  on  several  factors,  the  most 


COURSE  AND  PROGNOSIS  153 

important  being  the  virulence  of  the  infecting  gonococciis.  The  re- 
sistance of  the  tissues  and  the  intelligence  of  the  early  treatment  are  also 
of  importance. 

An  acute  gonorrhea  contracted  from  an  acute  gonorrhea  is  usually 
most  resistant  and  chronic.  But  this  also  depends  on  whether  the  infec- 
tion be  a  high  or  low  one.  Intelligent  treatment  at  the  onset  may 
affect  the  prognosis  materially.  Thus,  if  the  woman  be  impressed  with 
the  importance  of  constant  conscientious  treatment  much  may  be  hoped 
for.  In  cases  of  married  women  it  is  not  enough  to  treat  the  wife: 
the  husband  must  be  reached  in  some  tactful  manner  and  put  under 
treatment  and  sexual  intercourse  prohibited  during  the  course  of  the 
disease. 

Cases  of  mixed  infection  where  (at  the  time  of  infection)  the  gono- 
coccus  is  in  a  very  attenuated  form  and  the  pyogenic  organisms  active 
may  give  at  the  onset  the  clinical  picture  of  a  most  virulent  gonorrhea. 
These  cases,  however,  offer  a  good  prognosis  and  usually  make  a  satis- 
factory recovery. 

Two  cases  which  have  occurred  in  the  experience  of  the  writer  illus- 
trate the  foregoing  types. 

Miss  L — ■ — ,  age  eighteen,  came  to  my  office  complaining  of  a  burn- 
ing discharge  and  painful  burning  micturition.  On  examination  the 
vulva  was  found  to  be  the  seat  of  an  intense  inflammation,  the  hymen 
ruptured,  and  a  thin,  greenish  pus  discharge  pouring  down  from  the 
vagina.  On  further  questioning,  the  patient  admitted  that  she  had  been 
betrayed  by  her  lover.  A  smear  showed  abundant  gonococci.  She  ran  a 
very  acute  course  with  active  urethritis,  cystitis,  and  cervicitis.  Fortu- 
nately, the  infection  was  held,  at  the  cervix  and  the  uterus  and  tubes  not 
infected.  The  patient  has  been  most  faithful  as  to  treatment.  One  year 
after  the  first  visit  she  had  an  acute  appendicitis  and  I  advised  opera- 
tion. At  the  time  of  the  operation,  on  examining  the  uterus,  tubes,  and 
ovaries,  all  appeared  perfectly  normal.  This  case  is  still  under  observa- 
tion and  has  been  most  resistant  to  treatment.  She  has  a  chronic 
urethritis  and  cervicitis,  which  light  up  with  any  slight  indispositioa. 
Over  a  number  of  months  the  symptoms  are  gTadually  improving  and 
treatment  is  still  continued.  As  far  as  can  be  ascertained,  no  further 
indiscretions  have  occurred. 

Mrs.  W ,  age  twenty,  married  six  weeks:     History  of  difficult 

coitus,  vaginal  outlet  being  very  small,  and  as  a  result  considerable 
trauma.  Patient  complained  of  a  profuse  discharge  and  pain  in  right 
lower  abdomen.  Her  general  condition  poor,  she  ran  a  slight  tempera- 
ture, was  pale.  Examination  of  abdomen  showed  acute  tenderness  over 
McBurney's  point,  vaginally  a  violent  vulvitis  with  a  greenish  thin 
pus  pouring  down  from  the  vagina.  Smears  and  cultures  were  taken  for 
further  examination.    The  case  clinically  was  a  virulent  gonorrhea.    She 


154  GONORRHEA  IN  WOMEN 

was  kept  under  observation  for  about  twenty-four  hours,  during  wMcli 
time  active  douching  was  started;  bimanual  palpation  failed  to  show 
any  involvement  of  the  right  tube,  though  this  could  not  be  excluded  in 
the  presence  of  the  vaginal  discharge.  Operation  was  advised,  as  the 
temperature  and  tenderness  persisted.  I  removed  an  acute  appendix 
and  again  found  normal  uterus,  tubes,  and  ovaries.  The  wound  was 
closed  without  drainage  and  healed  by  primary  union.  The  vaginal 
condition  was  treated  with  protargol  (4  per  cent),  and  at  the  end  of 
a  week  all  active  inflammation  had  subsided.  Her  recovery  was  un- 
eventful. The  smear  and  culture  in  this  case  showed  a  very  attenuated 
gonococcus  and  staphylococci.  The  husband  was  approached  and  a 
history  of  a  gonorrhea  nine  to  ten  years  previous  to  marriage  obtained, 
the  husband  considering  himself  quite  well  at  the  time  of  his  marriage. 
He  was  referred  to  a  genito-urinary  specialist,  who  reported  that  he  had 
a  urethral  stricture  and  pus  in  his  urine.  The  husband  put  himself 
under  active  treatment  until  his  urine  had  cleared  up.  The  wife 
made  a  complete  recovery,  and  a  careful  examination  a  year  later  failed 
to  disclose  any  trace  of  the  inflammatory  process. 

Curability  of  Gonorrhea. — Can  gonorrhea  be  cured  in  women  ?  It 
would  seem  that  the  consensus  of  opinion  is  that  one  can  scarce  be  cer- 
tain of  a  cure. 

A  certain  percentage  of  cases  of  acute  urethritis  recover  completely. 
When  the  cervix  and  endometrium,  are  involved  the  question  of  a  posi- 
tive cure  becomes  more  uncertain. 

A  large  majority  of  these  cases,  after  careful,  persistent  treatment, 
are  apparently  cured  and  are  discharged  as  such.  It  is  impossible  to 
assure  such  a  patient,  however,  that  the  process  may  not  start  up  again 
at  some  time  under  various  conditions. 

Before  discharging  a  woman  as  practically  cured  she  should  prove 
the  following  examination : 

1.  That  leukorrhea  shall  have  ceased. 

2.  That  a  smear  and  culture  taken  from  the  cervical  secretion  shall 
show  no  gonococci. 

3.  That  Skene's  glands  shall  be  free  from  purulent  discharge. 

4.  That  Bartholin's  glands  and  ducts  shall  be  free  of  pus. 

5.  That  the  complement  fixation  test  shall  be  negative. 

These  tests  should  be  made  on  several  occasions  and  near  the  time 
of  the  menstrual  congestion,  l^o  douche  should  be  taken  before  the  ex- 
amination and  the  patient  advised  to  take  highly  seasoned  food  and 
stimulants,  which  may  excite  a  latent  process  into  activity. 


PROPHYLAXIS  155 


PROPHYLAXIS 


It  would  seem  that  a  very  great  deal  could  be  accomplished  along 
prophylactic  lines  in  handling  this  greatest  of  venereal  scourges  among 
women.     The  problems  to  be  met  readily  fall  into  two  classes: 

1.  Those  for  which  the  physician  is  solely  responsible.  Too  much 
stress  cannot  be  laid  upon  the  importance  of  absolute  asepsis  in  the  treat- 
ment of  gonorrheal  cases.  The  physician  should  be  scrupulously  careful 
as  to  his  hands,  gloves,  and  instruments.  All  instruments  should  be 
boiled  before  and  after  use  on  a  gonorrheal  case.  All  secretions  and 
dressings  from  a  gonorrheal  case  should  be  properly  gathered  in  some 
receptacle  (a  paper  bag)  and  later  burned.  The  utmost  care  should  be 
taken  in  regard  to  the  use  of  pessaries.  IvTo  pessary  which  has  been  worn 
by  a  patient  should  be  used  by  another  patient.  If  in  the  adjustment 
of  new  pessaries  several  have  been  used  in  order  to  obtain  a  satisfactory 
fit,  the  other  pessaries  can  be  boiled  (if  the  style  permit)  or  thoroughly 
cleansed  with  soap  and  water,  soaked  in  bichlorid  (1 :  500)  for  an  hour 
or  more,  and  finally  returned  to  the  stock. 

The  lubricant  used  in  vaginal  examination  may  also  be  a  source 
of  danger — the  old,  uncleanly  method  of  a  stock  jar  of  vaselin  or 
soapsuds  should  be  condemned  and  a  collapsible  tube  or  bottle  used 
instead. 

2.  The  second  class  of  problems  to  be  met  is  that  in  which  the 
patient  as  well  as  the  physician  plays  a  part.  The  youth  of  both  sexes 
should  be  instructed  in  the  physiology  of  sex  and  the  importance  of  per- 
sonal chastity. 

The  growing  girl  and  young  woman  should  be  informed  of  the  dan- 
ger of  gonorrheal  infection — that  it  may  be  contracted  from  dirty 
toilets,  towels,  douche  tips,  and  enema  outfits.  Oftentimes  the  family 
physician  can  impart  such  infoiTQation. 

The  infected  woman,  whether  she  be  innocent  or  guilty,  married  or 
prostitute,  should  be  warned  as  carefully  as  possible  of  the  infectious- 
ness of  her  condition.  The  physician  who  clumsily  imparts  such  knowl- 
edge and  breaks  up  a  marriage  relation  is  often  more  culpable  than 
if  he  had  left  matters  alone.  All  are  agreed  that  where  the  harm  has 
occurred,  the  added  wrecking  of  the  home  is  not  likely  to  help  matters. 

Gonorrhea  and  Marriage, — It  is  before  marriage  and  with  a  knowl- 
edge of  an  existing  infection  in  either  the  man  or  the  woman  that  the 
physician  should  speak. 

This  question  arises  much  more  frequently  on  the  part  of  the  man 
contemplating  matrimony  than  the  woman.  Statistics  state  that  80  to 
90  per  cent  of  men  have  or  have  liad  gonorrhea,  and  yet  of  those  how 
large  a  percentage  marry,  do  not  infect  their  wives,  and  hayo  healthy 


156  GONORRHEA  IN  WOMEN 

children !  It  would  seem  that  the  percentages  of  cures  among  men  was 
relatively  high  and  the  sterility  due  to  gonorrhea  relatively  low. 

Among  unmarried  gonorrheic  women  the  majority  belong  to  the 
prostitute  class,  and  this  class  is  notoriously  sterile.  It  is  seldom,  if 
ever,  that  the  marriage  consideration  comes  up  with  these  women. 

But  the  physician  is  occasionally  asked  to  pass  on  the  marriage  eli- 
gibility of  a  woman  who  has  had  a  gonorrhea.  How  shall  he  advise  her  ? 
Ignoring  the  fact  that  public  opinion  says  that  this  woman  has  not  the 
same  right  to  marriage  as  her  gonorrheic  brother,  the  physician  must 
pass  on  each  individual  case  as  an  entity. 

If  the  woman  can  pass  the  requirements  stated  above  the  physician 
may  assure  her  that  she  is  reasonably  sure  of  not  being  in  an  infectious 
state. 

If  she  has  previously  had  an  endometritis  or  salpingitis,  the  liability 
of  sterility  on  her  part  is  very  great  and  the  physician  should  frankly 
lay  this  before  her. 


CHAPTER    XVI 
GONORRHEAL  URETHRITIS  IN  THE  MALE 

Gonorrhea,  or  gonorrheal  urethritis,  is  the  most  venereal  of  all 
venereal  diseases,  since  it  is  the  commonest  malady  acquired  during  the 
copulative  act. 

A  most  respectable  antiquity  is  given  to  gonorrhea  by  the  fifteenth 
chapter  of  Leviticus,  although  it  is  contended  that  the  discharge  known 
to  the  Jewish  lawgiver  was  a  simple  urethritis,  and  that  gonorrhea  did 
not  appear  until  later  (according  to  Astruc  in  the  year  1545-46). 

ETIOLOGY 

Gonorrheal  urethritis  is  caused  by  implantation  of  the  gonococcus 
upon  the  urethral  mucous  membrane.  This  implantation  occurs  almost 
exclusively  in  sexual  contact.  It  is  quite  possible  for  the  male  to  ab- 
stract outlying  gonococci  from  the  vulva  of  a  timorous  partner  without 
effecting  intromission  (I  have  seen  two  instances  of  infection  thus 
acquired).  It  is  even  possible  to  transmit  gonococci  to  the  urethra  on 
the  fingers.  Less  direct  methods  of  contagion  may  be  looked  upon  with 
suspicion.  The  mythical  bathtub  and  the  legendary  privy  are  calcu- 
lated to  excite  derision.  However  certain  it  be  that  vulvovaginitis  in 
little  girls  commonly  results  from  indirect  contagion,  and  that  infec- 
tion of  an  adult  from  a  drop  of  pus  on  the  edge  of  the  closet  seat  is 
perfectly  possible,  it  is,  nevertheless,  singular  that  such  a  mode  of  in- 
fection is  alleged  almost  exclusively  by  persons  who  are  interested  in 
concealing  a  transgression. 

Frequently  enough  our  patient  relates  that  his  partner  was  "per- 
fectly clean."     Such  "perfect  cleanliness"  is  reducible  to  three  heads: 

1.  Usually  the  woman  is  supposed  to  be  exclusively  attached  to 
someone  else,  who  marches  about  in  apparent  health.  In  this  case  all 
three  of  the  parties  are  undoubtedly  gonorrheal,  the  suppliant  acutely, 
the  woman  perhaps  unconsciously,  the  accredited  proprietor  probably 
chronically.  This  explanation  is  founded  upon  the  assumption  that  a 
woman  may  have  gonorrhea  and  yet  think  herself  clean  (a  matter  of 
common  knowledge),  and  that  a  man  and  woman,  both  infected,  may 
cohabit  habitually  without  exciting  symptoms  of  gonorrhea  in  either. 

157 


158  GONORRHEAL  URETHRITIS  IN  THE  MALE 

I  have,  for  example^  had  two  persons  under  mv  care,  a  woman  (F) 
and  a  man  (M),  whose  history  may  be  summarized  as  follows: 

Spring,  1908,  F  infected  with  gonorrhea.  Prompt  "cure."  ISTo- 
vember,  1908,  F  leaves  her  paramour  and  attaches  herself  to  M. 
]\I  promptly  acquires  gonorrhea.  December,  1908,  M  consults  me. 
The  woman  is  "perfectly  clean."  She  has  acute  gonorrheal  arthritis.  I 
find  gonococci  in  M  and  in  F.  They  continue  to  cohabit  frequently. 
February,  1909,  gonococci  can  no  longer  be  found  either  in  M  or  F. 
There  have  been  no  further  symptoms  of  gonorrhea  in  either.  Local 
treatment  has  been  employed  by  both. 

2.  Sometimes  exposure  is  denied  on  the  score  that  the  male  has  worn 
a  condom.  In  such  a  case  the  gonococcus  has  been  acquired  during  pre- 
liminary skirmishing. 

3.  The  most  difficult  case  to  explain  is  that  in  which  the  woman  has 
been  examined  and  pronounced  clean  by  a  physician.  If  the  male  actu- 
ally harbors  the  gonococcus  and  has  cohabited  only  with  one  woman, 
sufficiently  careful  examination  of  that  woman  by  smear  and  comple- 
ment fixation  will  reveal  the  gonococcus. 

That  a  woman  may  pass  through  an  attack  of  acute  gonorrhea  and 
remain  infectious,  while  never  suspecting  that  she  is  diseased,  is  abun- 
dantly proven.  That  a  male  or  female  gonorrheic  may  cohabit  with  but 
one  partner  for  many  months  before  transmitting  the  infection  is  equally 
true.  We  scarcely  need  to  add  that  of  two  men  exposed  to  infection 
from  one  woman,  one  may  acquire  the  disease,  the  other  not. 


PATHOLOGY 

Urethral  gonorrhea  begins  as  an  acute  inflammation  at  the  meatus, 
whence  it  travels  inward  along  the  urethral  mucous  membrane.  Unless 
repressed  by  local  treatment,  this  inflammation  invariably  travels  as  far 
as  the  bulbous  urethra  and  usually  invades  the  posterior  urethra  as  well. 

Although  gonorrheal  inflammation  is  essentially  the  same  in  the 
anterior  as  in  the  posterior  urethra,  we  shall  describe  these  processes 
separately. 

The  cytology  of  gonorrheal  pus  has  been  studied  by  Joseph,^  Wile,^ 
Posner,^  jSI'euberger,'*  and  Taylor.^  The  results  obtained  are  nil.  The 
predominating  cell  is  polymorphonuclear.  The  eosinophil  is  always 
encountered,  but  does  not  harbor  gonococci  and  is  not  pathog-nomonic. 

^Arcliiv  f.  Dermat.  u.  Srjph.,  1905,  LXXVI,  65. 
^Am.  Jour.  Med.  Sci.,  June,  1906. 
'  Berl.  Jclin.  Wochenschr.,  November  7,  1906. 
*rirchow's  Archiv,  1907,  CLXXXVII,  No.  2. 
'^Jour.  Am.  Med.  Assoc,   1907,  XLIX,   1830. 


PATHOLOGY  159 

As  Taylor  says:  "All  of  this  detailed  study  of  cellular  elements  of 
gonorrheal  discharge,  interesting  as  it  may  be,  has  contributed  very 
little  to  our  understanding  of  the  nature,  prognosis,  or  treatment 
of  urethritis." 


PATHOLOGY  OF  ACUTE  ANTERIOR  URETHRITIS 

Onset. — The  most  accurate  data  we  possess  in  reference  to  the  in- 
vasion of  the  urethral  tissues  by  the  gonococcus  are  those  published  by 
Finger,  Gohn,  and  Schlagenhaufer.^  These  authors  inoculated  the 
urethrae  of  criminals  condemned  to  death,  and  were  able,  by  means 
of  immediate  post  mortem  examination,  to  investigate  the  various  stages 
of  invasion  of  the  tissues  by  the  specific  microbe.  Thirty-eight  hours 
after  inoculation  the  gonococci  had  only  just  begun  to  effect  an  en- 
trance between  the  epithelial  cells.  The  lacuna  of  Morgagni  was 
crowded  with  the  cocci,  diapedesis  had  begun,  and  intracellular  gono- 
cocci were  found  among  the  few  leukocytes  on  the  surface  of  the  epi- 
thelium. At  the  end  of  three  days  the  inflammatory  process  was  well 
under  way.  The  surface  of  the  mucous  membrane  was  covered  with 
pus,  its  epithelium  infiltrated  by  bacteria  from  one  side  and  by  leuko- 
cytes from  the  other.  The  inflammation  showed  four  striking  char- 
acteristics, viz. :  1,  The  pavement  epithelium  of  the  fossa  navicularis, 
although  swollen  with  leukocytes,  resisted  the  invasion  of  the  gonococci 
almost  absolutely;  2.  the  cylindrical  epithelium  of  the  penile  urethra 
was  generally  invaded ;  3.  this  invasion  was  most  marked  about  the 
crypts  and  glands,  which  were  packed  with  pus  and  gonococci ;  and  4. 
the  subepithelial  connective  tissue,  though  showing  every  evidence  of 
inflammation,  contained  few  gonococci,  except  in  the  neighborhood  of 
the  crypts  and  glands. 

Height.^When  the  inflammation  reaches  its  height  the  mucous 
membrane,  from  the  tumefied  meatus  to  the  bulbous  urethra,  is  intensely 
inflamed.  Its  surface  is  red  and  swollen,  covered  with  pus  and,  in 
places,  eroded  or  ulcerated.  The  epithelia  and  the  subepithelial  con- 
nective tissue  are  infiltrated  by  the  warring  gonococci  and  leukocytes. 

The  glands  and  crypts  form  the  most  important  centers  of  inflam- 
mation. They  are  implicated  in  the  general  process ;  inflamed  and 
distended  with  gonorrheal  pus.  The  gland  orifices  become  ob- 
structed by  the  tumefaction  of  the  mucous  membrane  and  the 
glands  thus  form  centers  whence  infiltration  (and  even  suppuration) 
extend  into  the  surrounding  tissues.  Since  the  glands  are  numer- 
ous and  extend  to  and,  in  some  instances,  even  into  the  corpus  spongio- 
sum, the  submucous  infiltration  (or  suppuration)  arising  from  them 
is  often  widespread  and  intense  at  the  height  of  an  acute  gonorrhea, 

^Arch.  f.  Dermat.  u.  Syph.,  1894,  XXVIII,  277. 


160  GONORRHEAL  URETHRITIS  IN  THE  MALE 

and  leaves  infiltrations  that  are  the  chief  cause  of  chronic  urethritis. 
Were  the  urethra  as  glandless  as  the  conjunctiva,  urethral  gonorrhea 
would  show  as  little  tendency  to  chronicity,  complications,  and  systemic 
absorption  as  does  conjunctival  gonorrhea. 

PATHOLOGY  OF  CHRONIC  ANTERIOR  URETHRITIS 

As  this  acute  inflammation  subsides  the  tissues  involved  may  return 
to  a  normal,  or  at  least  a  clinically  normal,  condition,  or  the  urethritis 
becomes  chronic.  The  transformation  of  an  acute  gonorrheal  anterior 
urethritis  into  a  chronic  condition  implies  certain  pathologic  and  bac- 
teriologic  changes,  as  follows : 

1.  The  inflammatory  periglandular  exudate  becomes  organized  into 
cicatricial  tissue  of  greater  or  lesser  density  and  extent,  according 
to  the  greater  or  lesser  intensity  and  distribution  of  the  acute  inflam- 
mation. 

2.  The  inflammation  within  the  glands  and  crypts  persists  as  a 
chronic  catarrh  (glandular  urethritis  of  Oberlaender),  or  the  orifice  of 
the  gland  is  occluded  and  the  inflamed  gland  becomes  a  purulent  or  col- 
loidal cyst  (dry  urethritis  of  Oberlaender),  or  the  glandular  inflamma- 
tion ceases  either  by  cicatricial  obliteration  or  by  return  to  normal  of 
the  gland.  These  changes  may  all  occur  in  the  same  urethra.  Chronic 
anterior  urethritis  is  therefore  denominated  by  the  urethroscopic  method 
in  accordance  with  its  predominant  feature.  The  submucous  glandular 
abscesses  are  minute  and  usually  terminate  by  rupture  within  the 
urethra,  exceptionally  by  invasion  of  the  surrounding  tissues  and  ex- 
ternal rupture. 

3.  The  surface  of  the  mucous  membrane  is  chronically  inflamed. 
The  inflammation  may  be  localized  over  one  or  more  small  areas  or  may 
be  general.  The  quality  of  the  surface  inflammation  depends  upon  the 
degree  of  submucous  sclerosis. 

If  the  sclerosis  is  slight  the  surface  is  swollen,  red,  and  eroded 
in  spots,  while  here  and  there  appear  the  inflamed  orifices  of  glands 
and  crypts.  The  urethroscope  shows  increased  redness,  diminution  of 
the  number  of  urethral  striae  and  folds,  and  red,  suppurating  duct 
orifices.  This  is  the  urethritis  mucosae^  the  soft  infiltration  of  Ober- 
laender. 

More  marked  sclerosis  causes  a  relative  anemia  of  the  overlying 
mucous  membrane  (after  the  redness  of  acute  inflammation  has  disap- 
peared), which  is  therefore  salmon  colored  or  grayish,  lighter  in  color 
than  the  adjacent  healthy  mucosa.  There  may  be  spots  of  opalescent 
whiteness,  where  the  chronically  inflamed  epithelium  has  been  trans- 
formed from  a  columnar  to  a  squamous  type  with  tendency  to  leuko- 
plakia; i.  e.,  heaping  up  of  this  squamous  epithelium  into  thick  "cal- 


PATHOLOGY  161 

lous"  masses.  Elsewhere  there  may  be  erosions,  ulcerations,  papillary 
outgrowths.  The  urethroscope  shows  a  pale  rigid  mucosa  with  striae 
and  folds  almost  or  quite  obliterated.  Here  and  there  one  sees  a  white 
patch  of  squamous  epithelium,  red  gland  orifices,  bleeding  erosions, 
ulcers,  or  papillomata.     This  is  the  hard  infiltration  of  Oberlaender. 

Still  more  marked  sclerosis  causes  urethral  stricture.  The  processes 
mentioned  in  the  preceding  paragraph  are  intensified.  The  rigid  ure- 
thral walls  do  not  yield  to  admit  urethral  instruments.  The  caliber  of 
the  urethra  is  more  or  less  diminished,  perhaps  almost  completely  oc- 
cluded. 

Hard  infiltrations  of  greater  or  less  degree  are  classified  by  Ober- 
laender as  hard  infiltrations  of  the  first,  second,  or  third  degree.  Hard 
infiltrations  of  the  first  degree  do  not  encroach  upon  the  urethral  caliber. 
Those  of  the  second  degree  diminish  the  caliber  of  the  urethra  to  such 
an  extent  that  large  instruments  ^  can  still  be  introduced,  but  only  at 
the  expense  of  more  or  less  laceration  of  the  epithelium.^  Those  of  the 
third  degree  do  not  admit  large  instruments  until  after  they  have  been 
dilated. 

These  more  or  less  arbitrary  subdivisions  correspond  to  clinical 
types  of  urethritis.  Yet  it  must  not  be  forgotten  that  they  are  but 
degrees  of  the  same  process.  Therefore,  while  the  mildest  form  of 
chronic  urethritis  may  exist  alone,  the  more  intense  "hard"  infiltrations 
are  at  first  always  accompanied  by  a  more  diffuse  "soft"  infiltration 
which  may  for  a  time  conceal  them. 

The  soft  infiltration  may  heal  spontaneously;  the  hard  infiltration 
requires  treatment  by  dilatation,  and  leaves  a  permanent  scar  in  the 
walls  of  the  canal. 

4.  The  flora  of  the  gonorrheal  urethra  undergoes  a  marked  change 
as  the  inflammation  becomes  chronic  (p.  166). 

PATHOLOGY  OF  POSTERIOR  URETHRITIS 

The  pathologic  changes  produced  by  gonorrhea  in  the  posterior 
urethra  are  essentially  the  same  as  those  produced  in  the  anterior  ure- 
thra. But  certain  anatomical  differences  vary  the  actual  conditions. 
These  are: 

In  the  membranous  urethra — 

The  relative  rarity  of  glands. 
In  the  prostatic  urethra — 

The  complexity  of  the  glands  immediately  beneath  the  mucous 

membrane. 
The  verumontanum. 
*  Oberlaender  makes  a  urethroscopie  tube  of  No.  23  F.  size  the  criterion. 
*This  is  the  "stricture  of  "large  caliber"  of  the  elder  Otis. 


162  GONORRHEAL  URETHRITIS  IN  THE  MALE 

The  great  complexity  of  the  internal  sexual  glands  (prostate, 
vesicles)  emptying  into  the  posterior  urethra. 
In  the  trigone — 

The  rarity  and  simplicity  of  glands. 
We  must,  therefore,  describe  gonorrhea  of: 

1.  The  membranous  urethra. 

2.  The  prostatic  urethra  and  verumontamun. 

3.  The  prostate. 

4.  The  seminal  vesicles. 

5.  The  trigone. 

6.  The  vas  and  epididymis. 

The  Membranous  Urethra. — The  glands  of  the  membranous  urethra 
are  relatively  few  and  simple.  Hence,  chronic  gonorrhea  of  the  mem- 
branous urethra  is  clinically  mild  and  is  overshadowed  by  the  in- 
flammation of  other  portions  of  the  canals.  Submucous  infiltrates  are 
usually  slight.  Stricture  is  rare,  chronic  glandular  catarrh  usually 
mild. 

The  Prostatic  Urethra. — The  relatively  large  and  complex  glands 
in  the  mucous  membrane  of  the  posterior  urethra  (p.  281)  and  the 
sinus  pocularis  of  the  verumontanum  form  nests  for  possible  abscess 
formation  during  acute  gonorrhea  of  the  posterior  urethra,  and  even 
after  the  acute  general  inflammation  has  passed. 

These  abscesses  are  larger  than  those  commonly  formed  in  the  glands 
of  the  anterior  urethra.  They  excite  fever  and  burst  into  the  canal  with 
a  recognizable  outpouring  of  pus. 

Chronic  Posterior  Urethritis. — The  urethral  mucosa  undergoes 
much  the  same  change  as  those  of  chronic  anterior  urethritis.  But  as 
the  inflammation  gTOws  less  it  may  become  localized  in  certain  special 
forms  as  follows : 

ViLLOsiTiES  (improperly  termed  papillomata  -^)  may  persist  in  vari- 
ous parts  of  the  posterior  urethra.  They  are  exuberant  granulations 
arising  from  a  small  ulcer. 

Follicular  Abscesses  ais'd  Cysts  are  rare.  They  usually  occur 
beyond  the  verumontanum. 

Yekumojsttai^^itis. — The  verumontanum  may  be  regarded  pathologi- 
cally as  a  hood  covering  the  prostatic  utricle.  Hence  a  chronically  in- 
flamed verumontanum  is  always  associated  with  utriculitis,  usually 
with  vesiculitis.  The  urethroscope  shows  a  swollen,  red  verumontanum, 
perhaps  much  hypertrophied  and  covered  with  gTanulations.  Irriga- 
tion of  the  utricle  usually  discloses  pus  in  its  cavity ;  amputation  of  the 
verumontanum  (Eytina  -)  shows  submucous  and  periacinous  round  cell 
infiltration. 

^Surg.,  Gynec.  and  Obstet.,  1913,  XVII,  548. 
'Jour.  A.  M.  A.,  1915,  LXLV,  45. 


PATHOLOGY  163 

Steictuke,  at  the  bladder  neck,  or  throughout  the  prostatic  urethra, 
is  rare.     It  is  attributable  to  chronic  sclerotic  prostatitis  (p.  285). 

The  Prostate. — The  prostate  is  implicated  in  almost  every  inflam- 
mation of  the  posterior  urethra.  Protatitis  is  by  far  the  most  im- 
portant complication  of  genital  gonorrhea  in  the  male.  It  is  frequent, 
it  is  intractable,  it  is  the  source  of  many  gTave  lesions  within  the  pros- 
tate itself,  and  is  a  port  of  entry  for  systemic  gonorrhea. 

Whereas  the  glandular  lesions  of  the  anterior  urethra  are  almost  ex- 
clusively due  to  gonorrhea,  the  prostate  may  be,  and  often  is,  inflamed 
by  other  bacteria. 

Three  types  of  prostatitis  are  recognized :  the  catarrhal,  the  follicu- 
lar, and  the  parenchymatous.  The  distinction  is  a  clinical  rather  than 
a  pathological  one.  In  the  prostate,  as  in  the  less  complex  glands  of  the 
anterior  urethra,  the  inflammation  is  a  suppuration  within  the  gland 
associated  with  more  or  less  surrounding  infiltration,  which  infiltration 
may  terminate  in  sclerosis  or  in  suppuration. 

Catakkhal  Prostatitis. — The  inflammation  extends  into  the  pros- 
tatic ducts,  but  spares  or  does  not  markedly  involve  the  acini.  The  in- 
flamed ducts  are  dilated,  filled  with  pus  and  debris.  The  surrounding 
stroma  is  but  little  infiltrated.  The  examining  finger  detects  no  change 
in  the  gland,  but  can  squeeze  pus  from  it.  The  diagnosis  is  not  made 
until  the  acute  posterior  urethritis  has  subsided,  leaving  the  chronic 
catarrhal  prostatic  lesion. 

FoLLicrLAE  Prostatitis. — The  infiammation  reaches  the  acini, 
which  are  distended  with  pus,  while  the  surrounding  stroma  is  infil- 
trated. In  the  acute  stage  the  prostate  is  congested,  tense,  sensitive. 
As  the  inflammation  becomes  chronic  the  general  congestion  disappears, 
leaving  the  gland  lumpy  to  the  touch.  The  lumps  are  constituted  by 
areas  of  diseased  acini,  suppurating,  cystic,  necrotic,  or  atrophic,  in  an 
indurated  stroma. 

Parenchymatous  Prostatitis. — The  follicular  involvement  is 
more  intense,  the  interstitial  inflammation  more  widespread  and  intense. 
Abscess  of  the  prostate  results.  The  suppuration  occurs  in  small  multi- 
ple foci,  few  or  many,  which  may  resolve  without  rupture,  or  coalesce 
to  form  a  large  prostatic  abscess  and  rupture  into  the  urethra  or  into 
the  ischiorectal  fossa,  or  rectum. 

Chrois'ic  Prostatitis. — Macroscopic  Changes. — To  the  examining 
finger  the  chronically  inflamed  prostate  may  show  no  change.  j\[ore 
commonly  it  is  enlarged.  This  enlargement  consists  of  a  general  bulg- 
ing of  one  or  both  lateral  lobes  or  the  presence  of  masses  of  induration 
in  or  about  the  gland. 

The  general  enlargement  of  a  lobe  may  be  tense  and  irreducible  by 
pressure,  or  it  may  soon  yield  to  massage,  leaving  in  its  place  a  sunken 
pit  surrounded  by  a  more  or  less  clearly  marked  rim  of  induration. 


164  GONORRHEAL  URETHRITIS  IN  THE  MALE 

With  this  subsidence  of  a  swollen  lobe  under  massage  there  is  an  out- 
pouring of  purulent  prostatic  secretion  from  the  meatus. 

The  indurations  may  be  prostatic  or  periprostatic.  They  are  irre- 
ducible by  massage,  but  usually  diminish  in  size  or  disappear  after  re- 
peated massaging  or  even,  in  time,  without  massaging. 

Microscopic  Changes. — "Periacinous  infiltration  is  so  invariably  present  that 
we  may  speak  of  it  as  the  essential  lesion  of  chronic  prostatitis.  Sometimes  it 
is  combined  with  more  extensive  interstitial  and  endoglandular  processes,  but  not 
infrequently  in  extensive  areas  the  periacinous  lesions  may  be  present  alone. 

"The  changes  in  the  acini  are  manifold.  In  some  instances  the  culdesacs  are 
dilated;  this  dilatation  .  .  .  may  be  due  to  stricture  or  obstruction  in  the 
excretory  ducts,  but  is  probably  more  often  the  result  of  an  accumulation  of 
inflammatory  products  in  the  glandular  sacs,  the  muscular  tone  of  whose  walls 
has  been  injured  by  the  inflammatory  process.  Acini,  however,  the  caliber  of 
whose  lumina  is  diminished,  are  almost  as  frequently  seen  as  are  dilated  ones, 
and  this  is  especially  true  where  the  prostatitis  is  of  long  standing  and  an 
extensive  periacinous  sclerosis  has  formed.  At  times  the  acini  are  mere  vestiges 
or  may  even  be  entirely  replaced  by  fibrous  tissue  in  areas  of  considerable 
extent.  The  acini  are  often  partially  or  entirely  filled  with  proliferating  and 
desquamated  epithelium"    (Young,  Geraghty,  and  Stevens). 

These  lesions  are  unevenly  distributed  about  the  gland.  Areas,  large 
or  small,  of  normal  gland  are  usually  present,  and  in  some  instances  the 
diseased  area  is  confined  to  that  part  of  the  gland  adjacent  to  the 
urethra. 

The  dilatation  of  the  acini  may  be  very  considerable.  This  dilata- 
tion is  the  foundation  for  Ciechanowski's  theory  of  the  inflammatory 
origin  of  prostatism. 

Changes  in  the  Secretion. — The  normal  prostatic  fluid  is  an  opales- 
cent fluid,  alkaline  to  litmus  (and  acid  to  phenolphthalein,  whence  the 
arguments  as  to  its  reaction).  As  obtained  by  massage,  it  usually  con- 
tains gelatinous,  transparent  masses  of  vesicular  secretion.  The  pure 
normal  prostatic  secretion  is  filled  with  minvite  lecithin  bodies.  It 
contains  a  moderate  number  of  columnar  and  round  epithelia  (the 
nuclei  of  the  latter  almost  fill  the  cell  body),  a  very  few  leukocytes, 
a  few  corpora  amylacea,  and  perhaps  red  blood  cells  from  the  trauma 
of  massage. 

The  abnormal  prostatic  secretion  is  purulent.  It  is  not  so  opalescent 
as  the  normal  secretion.  When  mingled  with  urine  (passed  after  mas- 
sage) it  often  looks  granular  and  flaky  to  the  experienced  eye.  There 
often  settles  at  the  bottom  of  the  glass  a  deposit  of  crumblike  purulent 
masses  (shreds).  The  normal  elements  are  in  inverse  proportion  to 
the  amount  of  pus.  The 'reaction,  like  that  of  the  nonnal  secretion,  is 
acid  or  alkaline  according  to  the  reagent  employed.  Bacteria  are  some- 
times present  in  great  numbers.    In  rare  instances  pus  is  only  obtained 


BACTERIA  OF  CHRONIC  URETHRITIS  165 

after  the  second  or  third  massage,  the  secretion  expressed  by  the  first 
manipulation  being  exclusively  from  the  normal  portions  of  the  gland. 

The  diagnosis  of  pus  in  the  prostatic  secretion  should  always  be  con- 
firmed by  the  microscope. 

Seminal  Vesicles. ^ — Seminal  Vesiculitis. — The  acute  changes 
caused  by  gonorrhea  of  the  seminal  vesicle  are  similar  to  those  in  the 
prostate,  with  this  exception — that  the  vesicle  is  a  gland  of  so  much 
larger  caliber  and  with  so  much  larger  a  duct  that  recognized  abscess 
in  it  is  uncommon,  and  its  parenchymatous  changes,  if  unaccompanied 
by  dilatation,  are  often  clinically  overlooked. 

Chronic  Vesiculitis. — The  normal  vesicle  is  impalpable  unless 
greatly  distended  with  semen.  Yet  the  vesicle,  like  the  prostate,  may 
be  inflamed,  though  apparently  normal  to  rectal  touch. 

The  walls  of  the  vesicle  are  infiltrated  and  matted  together  in  what 
is  pathologically  a  perivesiculitis.  This  may  or  may  not  result  in  a 
palpable  enlargement  of  the  gland.  The  mucosa  is  infiltrated  and 
eroded.  The  lumen  is  in  places  contracted  or  occluded  by  stricture,  in 
others  dilated.  This  general  dilatation  can  always  be  demonstrated 
by  injection  of  argyrol  into  the  vas.  In  long-standing  cases  the  vesicle 
may  be  changed  from  its  normal  state — a  branching  ramifying  canal — 
to  an  irregTilar  cavity  containing  several  c.c.  of  pus.  Chronically  in- 
flamed vesicles  have  been  appropriately  termed  by  Belfield  -  "pus  tubes 
in  the  male." 

Vesiculitis  is  always  bilateral,  often  impalpable. 

Secretion. — The  secretion  of  the  normal  vesicle  varies  in  consistency 
from  thick  gelatinous  to  sticky  and  ropy.  The  microscope  shows  mu- 
coidal  masses  entangling  spermatozoa,  sympexia,  and  epithelial  cells. 
The  color  is  usually  opalescent,  but  may  be  rusty,  especially  in  older 
persons,  from  pigmentation  of  the  contained  epithelia.  When  sper- 
matozoa are  absent  Boettcher's  crystals  are  usually  found.  The  vesicu- 
lar secretion  floats  (in  part)  in  water,  whereas  the  prostatic  secretion 
sinks. 

The  secretion  of  an  inflamed  vesicle  contains  pus  and  bacteria.  Live 
spermatozoa  are  sometimes,  though  not  often,  found  in  purulent  vesicu- 
lar secretion. 


BACTERIA  OF  CHRONIC  URETHRITIS 

The  occurrence  of  mixed  infection  in  chronic  urethritis  is  due  usu- 
ally to  the  bacteria  harbored  by  the  normal  urethra,  rarely  to  contamina- 
tion by  instruments.     Moreover,  the  bacterial  findings  are  not  quite  the 

^Cf.  Palozzoli,  Bev.  chir.  d.  urol.,  1914,  Jan.,  Feb.,  Mar. 

'Jour.  A.  M.  A.,  1909,  liii,  21-43.     Also  Thomas,  Ann.  Surg.,  Sept.,  1914. 


166  GONORRHEAL  URETHRITIS  IN  THE  MALE 

same  in  clironic  anterior  urethritis  and  in  chronic  prostatitis.    Hence  we 
must  consider: 

The  bacteria  of  the  healthy  interior  urethra ; 
The  bacteria  of  chronic  anterior  urethritis,  and 
The  bacteria  of  chronic  prostatitis. 

Bacteria  Found  in  the  Healthy  Anterior  Urethra.^ — Pfeiffer  exam- 
ined 24  urethrae,  and  found  diphtheroid  bacilli  in  21,  streptobacillus 
in  10,  staphylococcus  pyogenes  aureus  in  5,  miscrococcus  candicans  in  4, 
sarcina  alba  in  14.  Petit  and  Wassermann  found  5  kinds  of  cocci,  6 
kinds  of  bacilli.  Franz,  in  56  urethrae,  found  the  sarcina  once,  the 
bacillus  coli  once,  pyogenic  staphylococci  6  times,  streptococci  twice, 
and  7  other  varieties  of  cocci  and  4  varieties  of  diplococci. 

These  bacteria  are  usually  found  at  or  near  the  meatus.  The  deeper 
portion  of  the  anterior  urethra  is  often  sterile. 

Bacteria  of  Chronic  Anterior  Urethritis — Of  154  cases  -  examined 
20  were  sterile,  10  showed  gonococci  alone,  10  gonococci  mixed  with 
other  bacteria,  114  other  bacteria  without  gonococci. 

Of  von  Hoffmann's  cases,  the  gonococcus  apart,  18  showed  pseudo- 
diphtheria  bacillus,  12  streptobacillus  urethrae,  2  bacillus  subtilis,  3 
sarcina  alba,  1  proteus  vulgaris,  1  bacillus  coli,  1  Friedlander's  bacillus. 
He  also  found  27  kinds  of  staphylococci,  3  other  cocci,  and  6  kinds  of 
bacilli. 

Bacteria  of  Chronic  Prostatitis.— Young,  Geraghty,  and  Stevens,^ 
examined  19  cases  (2  nongonorrheal)  and  obtained  a  growth  on  agar 
in  only  8.  The  staphylococcus  albus  was  identified  thrice,  the  strepto- 
coccus pyogenes  twice.  The  anterior  urethra  was  copiously  irrigated 
and  the  prostatic  secretion  obtained  through  a  sterile  urethroscopic  tube. 
Control  cultures  were  made  from  the  bulbous  urethra. 

ISTotthaft,  using  less  careful  methods,  examined  120  cases.  He  found 
the  gonococcus  alone  in  5  cases,  all  within  eighteen  months  of  the  time 
of  infection ;  the  gonococcus  alone  or  with  other  bacteria  in  60  per  cent 
cases  of  less  than  eighteen  months'  duration,  in  18  per  cent  cases  of 
from  eighteen  to  twenty-four  months'  duration,  in  6  per  cent  cases  of 
from  twenty-four  to  thirty-six  months'  duration.  The  gonococcus  was 
not  found  after  the  third  year.  The  gonococcus  was  found  47  times, 
other  micrococci  119  times,  bacilli  were  found  15  times,  other  bacteria 
14  times. 

Cohn,  in  12  cases,  found  staphylococcus  albus  11  times,  streptococcus 
3  times,  bacillus  coli  once,  other  bacteria  thrice ;  no  gonococcus. 

Bacteria  of  Chronic  Vesiculitis. — Gonococci  are  very  rarely  found 
in  the  chronically  inflamed  vesicle.     Cultures  are  often  sterile.     The 

^  Von  Hoifmann,  CentralU.  f.  Ham  u.  Sex.  Org.,  1904,  xv,  569. 
^Keported  by  Tano,  Cohn,  Owens  and  von  Hoffmann. 
•Johns  Hopkins  Hospital  Eeports,  1906,  xiii,  276. 


BACTERIA  OF  CHRONIC  URETHRITIS  167 

flora  includes  staphylococcus,  streptococcus,  bac.  lactis  aerogenes,  and 
bac.  coli. 

Summary. — Thus  the  gonococci  that  swarm  in  the  discharges  of 
acute  gonorrhea  are  by  no  means  always  present  in  chronic  gonorrheal 
urethritis  and  prostatitis.  ISTotthaft  ^  quotes  in  favor  of  his  thesis  that 
they  disappear  from  the  prostate  always  within  three  years,  often  within 
eighteen  months,  the  names  of  I^Teisser,  Finger,  Frank,  Wassidlo,  Jadas- 
sohn, Goldberger,  and  others.  The  thesis  may,  I  believe,  be  extended 
to  include  all  the  urethral  glands.  I  have  seen  but  one  apparently  au- 
thentic case  in  which  gonococci  persisted  for  three  years  in  the  urethral 
secretion;  not  more  than  three  or  four  in  which,  in  spite  of  vigorous 
treatment,  they  persisted  for  over  two  years.  Earnest  investigation  dur- 
ing the  past  three  years,  with  the  aid  of  the  complement  deviation  test, 
has  served  only  to  confirm  this  belief.  The  rule  is  almost  without  ex- 
ception that  a  chronic  gonococcic  urethritis  ceases  to  show  gonococci  in 
its  secretion  within  three  to  six  months  of  the  beginning  of  intelligent 
local  treatment. 

^  Archiv  f.  Derm.  u.  Syph.,  1904. 


CHAPTER  XVII 

SYMPTOMS,  COURSE,  AND  COMPLICATIONS  OF  ACUTE  URETHRAL 
GONORRHEA  IN  THE  MALE 

Since  acute  gonorrhea  of  the  male  urethra  always  begins  with  in- 
flammation of  the  balanitic  urethra,^  continues  by  direct  extension  of 
the  inflammation  along  the  urethral  mucous  membrane,  and  may 
terminate  before  the  inflammation  reaches  the  posterior  urethra,  to  be 
accurate  we  should  speak  of  anterior  urethritis  alone  as  essential  gonor- 
rheal urethritis  and  class  all  other  gonorrheal  inflammations,  including 
posterior  urethritis,  as  complications.  But  inasmuch  as  the  average 
uncontrolled  urethral  gonorrhea  invades  the  posterior  urethra,  the 
trigone,  and  the  prostate,  it  is  clinically  convenient  to  group  anterior 
urethritis,  posterior  urethritis,  and  prostatitis  in  the  type  description 
of  the  disease  and  to  follow  with  a  description  of  other  inflammations  as 
complications.  Accordingly,  we  shall  describe: 
The  incubation. 

Typical  acute  gonorrheal  urethritis. 
Atypical  acute  gonorrheal  urethritis. 
Prolonged  or  complicated  cases. 
Mild  cases. 
Severe  cases. 

Cases  modified  by  treatment. 
Complications  of  acute  anterior  urethritis. 
Abscess  of  the  urethral  glands. 
Periurethritis  and  periurethral  abscess. 
Inflammation  of  the  erectile  tissues. 
Balanoposthitis,  lymphangitis,  lymphadenitis. 
Complications  of  acute  posterior  urethritis. 
Prostatitis. 
Prostatic  abscess. 

Seminal  vesiculitis  and  deferentitis. 
Epididymitis. 
Cystitis. 
Pyelonephritis. 
Peritonitis. 
^Excepting  cases  of  reinfection   of  the  urethra  from   gonoeocei  that  have  lain 
quiescent  in  the  urethral  glands,  which  cases  are  properly  classed  as  relapses. 

168 


TYPICAL  ACUTE  GONORRHEAL  URETHRITIS 


169 


INCUBATION  OF  GONORRHEAL  URETHRITIS 

The  incubation  period  of  gonorrhea  varies  from  two  to  seven  days. 
The  earlier  authors  recognized  longer  incubation  periods.  Yet  I  con- 
fess to  some  suspicion  of  inaccuracy  in  reference  to  those  cases  on  the 
subjoined  list  that  give  a  story  of  more  than  a  week's  incubation.  Per- 
haps some  of  them  had  very  long  foreskins. 

Experimental  inoculation  produces  a  discharge  on  the  second,  third, 
fourth,  or  fifth  day ;  but  it  has  been  my  experience  that  the  shorter  in- 
cubations are  clinically  due  to  the  association  of  sexual  strain  or  of 
simple  urethritis  with  the  gonococcus.  Such  a  condition  may  be  ex- 
pected to  occur  most  often  in  the  damaged  urethra  of  the  roue;  hence 
the  relatively  large  number  of  short  incubations  among  recurrences  as 
compared  with  first  attacks. 

Length  of  Incubation'' 


Day. 

First  Attack. 

Recurrence. 

1 

0 
2 
2 
3 
11 
6 
4 

0 

cases. 

<  ( 

<  ( 
<( 
<( 
(( 

case. 
( I 

tc 

11 

11 

It 

2 

12 

15 

13 

10 

4 

10 

2 

1 

4 

1 

0 

0 

2 

cases. 

2 . 

3 

4 

5 

6 

7 

8 

9 

case. 

10 .  . 

cases. 

11 

case. 

12 

13 

14 - 

eases. 

Total 

34 

76 

Average  incubation  of  34  primary  attacks,  6  days. 

Average  incubation  of  76  secondary  attacks,  4.88  days. 

Of  the  primary  attacks,  20  per  cent  appeared  before  the  fifth  day;  61  per  cent 
on  the  fifth,  sixth,  and  seventh. 

Of  the  secondary  attacks,  5.5  per  cent  appeared  before  the  fifth  day;  31  per  cent 
on  the  fifth,  sixth,  and  seventh. 

TYPICAL  ACUTE  GONORRHEAL  URETHRITIS 


Onset — A  tickling,  teasing,  itchy  irritation  is  felt  at  the  orifice  of 
the  urethra.     The  lips  of  the  meatus  are  found  adherent,  or  a  bhiisli, 

*  I  have  included  in  this  list  only  those  cases  in  wliicli  the  incubation  period  was 
unmistakable  and  the  disease  absolutely  characteristic — microscopically,  clinically, 
or  both. 


170      ACUTE  URETHRAL  GONORRHEA  IN  THE  MALE 

sticky  discharge  is  seen  between  tliem.  A  slight  stinging  is  felt  on  urina- 
tion. The  lips  of  the  meatus  now  swell  slightly  and  redden.  The  quan- 
tity of  discharge  increases  and  it  becomes  frankly  purulent.  The 
meatus  feels  hot  and  sore.     The  pain  on  urination  increases. 

Height — In  a  period  varying  from  a  few  hours  to  two  or  three 
days  the  inflammation  reaches  its  height  at  the  meatus  and  has  invaded 
the  greater  part  of  the  anterior  urethra.  The  symptoms  of  anterior 
urethritis  are  swelling  of  the  meatus,  purulent  discharge,  painful  urina- 
tion, and  painful  erections. 

The  Swollen  Meatus. — The  lips  of  the  meatus  are  red,  swollen, 
everted,  sometimes  eroded.  Their  tumefaction  is  almost  pathog-nomonic 
of  gonorrhea.  It  begins  with  the  disease  and  usually  subsides  during 
the  second  or  third  week,  long  before  the  subsidence  of  the  inflamma- 
tion of  the  deeper  portion  of  the  urethra.  It  is  less  constant  and  less 
marked  with  secondary  than  with  primary  attacks. 

The  Discharge. — The  drop  of  thick  greenish-yellow  pus  constantly 
exuding  from  the  swollen  meatus  completes  the  outward  picture  of  acute 
gonorrhea.  Blood  may  appear  in  the  discharge  from  time  to  time.  The 
pus  ceases  to  be  thick  and  creamy  some  time  after  the  swelling  of  the 
meatus  has  subsided.  It  becomes  less  in  quantity  and  more  watery  and 
opalescent  in  quality  as  the  acute  inflammation  of  the  anterior  urethra 
declines. 

The  Pain  on  Ueination. — The  urethral  mucous  membrane  is 
swollen,  sensitive,  and  eroded.  Hence,  the  passage  of  urine  is  painful, 
the  stream  slow  and  obstructed. 

The  pain  due  to  anterior  urethritis  reaches  its  height  within  ten  to 
fourteen  days  and  begins  to  subside  between  the  fourteenth  and  the 
twenty-fifth  day. 

The  Painful  Eeections. — The  urethral  inflammation  encourages 
nocturnal  erections.  The  inflamed  membrane  is  relatively  inelastic, 
hence  these  erections  are  exceedingly  painful.  The  inflamed  surface  may 
be  so  cracked  and  fissured  that  it  bleeds  copiously.  Since  the  corpora 
cavernosa  retain  their  normal  distensibility,  the  inelastic,  inflamed 
urethra  is  pulled  taut  beneath  them  when  the  penis  is  erect,  so  that  in 
severe  cases  the  organ  is  bent  downward,  while  the  pain  is  excruciating. 
This  phenomenon  is  called  cJiordee. 

Painful  erections  may  continue  for  days  after  the  surface  of  the  an- 
terior urethra  has  ceased  to  be  sensitive  to  the  passage  of  urine. 

Invasion  of  the  Posterior  Urethra  and  Prostate It  is  clinically 

impossible  to  distinguish  acute  posterior  urethritis  from  acute  pros- 
tatitis, and  although  in  some  instances  the  posterior  urethra  is  involved 
and  the  prostate  apparently  spared,  this  cannot  be  determined  until 
after  the  disease  has  become  chronic. 

The  frequency  of  posterior  urethritis  in  acute  gonorrhea  is  esti- 


TYPICAL  ACUTE  GONORRHEAL  URETHRITIS  171 

mated  variously.  Van  der  Poel  estimates  it  at  60  per  cent,  Wassidlo 
quotes  various  authors  at  from  80  per  cent  to  92  per  cent.  Prostatitis  is 
estimated  to  complicate  about  70  per  cent  to  80  per  cent  of  acute 
posterior  urethritis,  though  Columbini  places  it  as  low  as  36  per  cent. 

The  confusion  in  these  figures  is  due  to  the  various  means  of  exam- 
ination employed.  Subjective  symptoms  of  posterior  urethritis  are 
excited  by  the  majority  of  initial  gonorrheas,  are  less  common  in 
subsequent  attacks,  and  are  rare  in  office  patients  treated  by  repressive 
measures.  On  the  other  hand,  if  pus  in  the  second  flow  of  urine  is 
taken  as  a  criterion,  the  percentages  run  much  higher.  Let  us  be  satis- 
fied to  say  that  acute  posterior  urethritis  is  extremely  common  and 
usually  associated  with  prostatitis. 

Posterior  urethritis  usually  appears  between  the  fifth  and  the  fif- 
teenth day  of  acute  gonorrhea. 

Symptomless  Cases. — The  figures  given  in  the  preceding  para- 
graph illustrate  the  frequency  with  which  gonorrhea  invades  the  pos- 
terior urethra  without  causing  subjective  symptoms. 

The  evidence  of  this  invasion  is  pus  in  the  second  flow  of  urine  or 
palpable  enlargement  of  the  prostate. 

It  is  probable  that  in  these  symptomless  cases  the  prostatic  urethra 
is  only  mildly  inflamed,  the  trigone  spared  altogether. 

Symptoms  of  Acute  Posteeiok  Ueetheitis  axd  Tkigoxitis 
(Cystitis). — The  symptoms  of  acute  gonorrheal  posterior  urethritis, 
trigonitis,  or  cystitis  are  all  referable  to  the  irritation  at  the  bladder 
neck.  This  causes  frequent  and  urgent  urination,  painful  urination, 
and  terminal  hematuria. 

Frequent  and  Urgent  Urination. — So  long  as  the  pain  of  urination 
is  due  solely  to  anterior  urethritis  the  patient  urinates  as  rarely  as 
possible.  When  it  is  due  to  posterior  urethritis  he  miLst  urinate  fre- 
quently. As  soon  as  a  relatively  small  amount  of  urine  has  collected 
in  the  bladder  an  urgent  call  to  urinate  is  felt;  a  call  that  will  not  be 
denied.  If  the  victim  does  not  quickly  acquiesce  he  irrigates  his  trouser 
leg:.  The  frequency  of  this  urgent  call  may  be  so  gTeat  that  the  patient 
dribbles  away  a  few  drops  of  purulent  urine  every  ten  or  fifteen  minutes 
night  and  day.  A  frequency  of  less  than  once  in  two  hours  may  be 
accounted  mild. 

Painful  Urination. — The  pain  of  posterior  urethritis  is  more  con- 
stant than  that  of  anterior  urethritis,  and  is  often  referred  to  some 
point  on  the  surface  of  the  body,  usually  the  perineum,  the  auterior 
urethra  just  back  of  the  glans,  or  the  ejjigastrium. 

The  pain  at  urination  in  posterior  urethritis  has  several  striking 
characteristics.  '  It  appears  before  urination,  as  we  have  just  seen,  in 
the  form  of  urgency.  During  urination  the  posterior  urethra  can  be 
more  exquisitely  sensitive  than  the  anterior  urethra.     Put  it  is  at  the 


172      ACUTE  URETHRAL  GONORRHEA  IN  THE  MALE 

end  of  urination  that  the  full  force  of  this  pain  is  felt.  As  the  muscles 
of  bladder  and  urethra  contract  to  expel  the  last  drops  of  urine  the  in- 
flamed surface  is  violently  wrenched.  The  resultant  pain,  like  that  of 
anal  fissure,  is  a  spasm  or  series  of  spasms  that  may  last  for  many  sec- 
onds after  the  bladder  has  emptied  itself.  In  severe  cases  the  patient 
may  be  said  to  pass  from  one  terminal  urinary  spasm  to  another. 

Terminal  Hematuria. — The  intensity  of  the  inflammation,  together 
with  the  incessant  trauma  of  the  frequent  urination,  often  excite  bleed- 
ing from  the  posterior  urethra.  This  bleeding  may  be  constant  or  inter- 
mittent. In  either  case  the  amount  of  blood  lost  is  not  gTcat,  and  the 
three-glass  test  reveals  terminal  hematuria;  i.e.,  whether  the  body  of 
the  urine  be  bloody  or  not,  the  last  jet  is  almost  pure  blood.  Terminal 
hematuria  is  caused  by  terminal  spasm. 

The  Decline. — The  inflammation  subsides  first  where  it  first  began, 
i.  e.,  at  the  meatus.  The  meatal  inflammation  often  disappears  in  the 
second  or  third  week,  while  the  inflammation  is  elsewhere  at  its  height. 
In  the  rest  of  the  anterior  urethra  the  inflammation  usually  begins  to 
decline  in  the  third  or  fourth  week ;  the  discharge  becomes  thinner  and 
more  watery,  the  erections  less  painful.  The  pain,  frequency,  and 
bleeding  that  mark  posterior  urethritis  may  begin  to  diminish  at  almost 
the  same  time. 

In  the  fourth  or  fifth  week  the  patient's  symptoms  are  reduced  to  a 
semipurulent  discharge,  which  grows  less  and  less  in  quantity.  From 
the  sixth  to  the  eighth  week  this  discharge  usually  continues  almost  or 
quite  exclusively  as  "a  morning  drop,"  a  drop  of  pus  appearing  at  the 
meatus  only  before  the  first  morning  urination ;  during  the  rest  of  the 
day  the  urethra  is  apparently  clean.  ISTow  the  patient  fancies  himself 
well.  But  examination  of  the  urine  still  reveals  pus;  examination  of 
this  pus  still  reveals  gonococci. 

It  is  rare  for  the  gonococci  and  pus  to  disappear  within  six  weeks. 
It  is  common  for  them  to  persist  eight  to  twelve  weeks. 

By  common  consent  the  gonorrheal  urethritis  of  less  than  two 
months'  duration  is  called  acute,  of  more  than  three  months'  duration 
chronic.  The  division  is  purely  arbitrary,  but  it  voices  the  fact  that 
acute  gonorrhea  is  often  cured  in  from  eight  to  twelve  weeks. 


ATYPICAL  ACUTE  GONORRHEAL  URETHRITIS 

The  good  or  evil  fortune  of  the  patient  in  his  choice  of  a  physician 
as  well  as  in  his  reaction  to  the  disease  so  influences  the  course  of  each 
individual  case  of  gonorrhea  that  the  attempt  to  separate  "typical" 
from  "atypical"  cases,  though  justified  by  expediency,  has  no  founda- 
tion in  clinical  fact.     The  above  description  of  a  "typical  acute  gon- 


ATYPICAL  ACUTE  GONORRHEAL  URETHRITIS  173 

orrheal  urethritis"  describes  many  cases  in  general  but  none  in  par- 
ticular.    Every  case  is  actually  '^atypical"  to  a  greater  or  less  degree. 

Prolonged  or  Complicated  Cases — What  proportion  of  gonorrheics 
become  chronic  I  do  not  know.  In  the  clinic  most  cases  approach  the 
three-months'  limit  and  perhaps  half  surpass  it.  In  private  practice, 
by  the  aid  of  repressive  measures,  we  get  better  results. 

But  practically  every  unrepressed  case  of  gonorrhea  is  a  "compli- 
cated" case.  Some  one  of  the  complications  mentioned  below  almost 
invariably  arises  unless  repressive  measures  are  employed. 

Mild  Cases. — The  initial  gonorrhea  is  quite  invariably  severe.  Sub- 
sequent infections,  especially  if  often  repeated,  may  run  a  much  milder 
course;  so  mild,  indeed,  that  it  might  be  quite  impossible  to  determine 
when  a  given  patient  was  last  infected.  The  bearing  of  this  fact  upon 
the  alleged  persistence  of  gonococci  in  urethral  pus  for  many  years  in 
exceptional  instances  is  most  important. 

Reinfections  may  excite  merely  a  slight  mucopurulent  discharge 
with  the  least  possible  subjective  irritation.  The  acute  attack  may  last 
but  a  week  or  so.  Yet  from  such  an  infection  gonococci  may  persist  in 
the  urethra  quite  as  long  as  though  the  attack  had  been  most  severe. 
Moreover,  the  urethra  thus  inflamed  may  resent  instrumental  or  other 
traumata,  though  the  reaction  to  these  is  not  so  fierce  as  when  the  ure- 
thral inflammation  is  more  intense. 

Acute  Reinfections. — Sharp,  short  reinfections  of  the  anterior  ure- 
thra,.with  copious  creamy  discharge,  yet  lasting  but  a  few  hours  or  a 
few  days,  are  more  often  due  to  reinfection  from  the  patient's  own 
secretions  (occasioned  by  instrumentation,  sexual  or  alcoholic  excess, 
spontaneous  rupture  of  follicular  abscess,  etc.)  than  to  fresh  infection 
acquired  from  without.  The  striking  feature  of  such  reinfections  is 
their  brevity:  the  contrast  between  the  profuse,  creamy,  gonococcus- 
laden  discharge  of  today  and  the  entire  absence  of  all  symptoms 
tomorrow. 

Severe  Cases — Urethral  gonorrhea  may  be  severe  in  its  onset 
(prompt  involvemant  of  posterior  urethra  or  epididymis,  early  appear- 
ance of  complications,  intensity  of  subjective  symptoms),  in  its  com- 
plications; or  in  the  severity  or  duration  of  its  acute  symptoms. 

Thus  chordee,  or  the  pain  and  frequency  of  posterior  urethritis, 
may  be  almost  or  quite  the  first  symptoms  complained  of;  epididymitis, 
even,  may  apparently  begin  the  attack.  Yet,  unless  they  be  autore- 
infections,  it  is  not  correct  to  classify  such  outbreaks  as  beginning  in  the 
posterior  urethra  or  in  the  epididymis. 

The  prolongation  of  intense  chordee  or  posterior  urethritis  through 
many  weeks  occurs  just  often  enough  to  remind  us  of  the  total  lawless- 
ness of  gonorrheal  inflammations. 

Cases  Modified  by  Treatment.—  The  local  treatment  now  almost 


174      ACUTE  URETHRAL  GONORRHEA  IN  THE  MALE 

universally  employed  througlioiit  acute  gonorrhea  always  materially 
modifies  the  course  of  the  disease.  If  successful  it  ameliorates  all  the 
symptoms  and  minimizes  the  danger  of  complications;  if  unsuccessful, 
it  intensifies  the  urethral  inflammation,  excites  complications,  or  en- 
courages chronicity. 


COMPLICATIONS  OF  ACUTE  ANTERIOR  URETHRITIS 

Abscess  of  the  Urethral  Glands. — Minute  abscesses  due  to  obstruc- 
tion of  the  ducts  of  suppurating  glands  doubtless  occur  and  pass  un- 
noticed amidst  the  intense  symptoms  of  every  acute  urethral  gonorrhea. 
Such  abscesses  occurring  during  the  declining  stage  cause  a  character- 
istic brief  explosion  of  acute  symptoms.  After  a  day  or  more  of  vague 
localized  uneasiness  or  itching  a  sharp  reinfection  of  the  urethra  occurs. 
The  discharge  becomes  profuse  and  creamy ;  the  meatus  may  even  swell, 
but  there  is  usually  no  pain.  But  no  sooner  has  the  patient  decided  that 
he  must  look  forward  to  weeks  more  of  suffering  than  the  discharge 
abates  almost  as  suddenly  as  it  appeared. 

This  sudden  abatement  of  discharge  is  doubtless  due  to  local  im- 
munity persisting  from  the  preceding  acute  urethritis.  It  is  exceptional 
for  this  immunity  to  be  so  slight  as  to  permit  prolonged  relapse. 

Periurethritis  and  Periurethral  Abscess Extension  of  suppura- 
tion from  an  infected  urethral  gland  to  the  periurethral  connective 
tissue  is  to  be  expected  only  as  a  result  of  overtreatment  or  of  scars 
left  by  antecedent  gonorrheas. 

The  suppuration  arises  from  the  balanitic,  the  pendulous,  or  the 
bulboperineal  portions  of  the  anterior  urethra. 

Abscesses  arising  from  the  balanitic  portion  of  the  canal  appear  at 
one  or  both  sides  of  the  preputial  frenum.  They  grow  rapidly  and,  hav- 
ing opened  or  been  incised,  often  leave  permanent  fistulae  requiring  a 
special  procedure  for  their  cure. 

Abscess  of  the  pendulous  urethra  usually  projects  from  the  floor  of 
the  canal  as  a  hard  nodule.  It  may  grow  quite  slowly  and  may  resolve 
or  break  into  the  urethra.  But  it  is  far  more  likely  to  invade  the  skin 
and  point  directly  opposite  to  its  point  of  origin,  or  to  travel  beneath  the 
fascia  for  a  considerable  distance  before  discharging  externally,  unless 
its  course  is  cut  short  by  incision.     The  fistula  heals  spontaneously. 

Abscess  of  the  perineal  urethra  is  usually  spoken  of  as  abscess  of 
Cowpers  gland,  though  it  is  impossible  to  say  in  what  proportion  of 
cases  this  gland  is  actually  the  one  involved.  The  inflammatory  mass 
often  appears  to  one  side  of  the  median  line  and  usually  travels  to  a 
distance  beneath  the  deep  fascia  before  breaking  through  this,  thus 
causing  extensive  perineal  infiltration,  if  not  promptly  incised. 


COMPLICATIONS  OF  ACUTE  POSTERIOR  URETHRITIS        175 

All  of  these  processes  travel  forward,  so  that,  while  abscess  origi- 
nating in  the  pendulous  urethra  never  points  in  the  perineum,  perineal 
abscess  may  show  itself  prominently  only  about  the  pendulous  urethra. 
The  attachment  of  the  deep  fascia  to  the  anterior  layer  of  the  triangular 
ligament  prevents  extension  of  perineal  suppuration  backward. 

Inflammation  of  the  Erectile  Tissues. — Spongeitis  and  cavernitis 
are  extremely  rare  complications  of  gonorrhea,  if  we  except  that  type  of 
the  former  that  manifests  itself  in  chordee. 

Thrombophlebitis  of  the  erectile  tissues  or  inflammation  of  the 
fibrous  envelopes  manifest  themselves  as  sensitive  indurations  of  the 
erectile  bodies.  Under  appropriate  treatment  they  usually  resolve,  but 
they  may  suppurate  and  require  incision. 

Balanoposthitis. — The  gonorrheic  with  a  long  or  tight  foreskin 
usually  develops  balanoposthitis  in  spite  of  all  his  care.  Yet  the  com- 
plication is  rarely  severe.  It  has  no  peculiar  characterictics,  is  appar- 
ently due  to'  mixed  infection,  and  readily  yields  to  the  usual  treatment. 

Lymphangitis  and  Lymphadenitis. — These  complications  are  rare, 
inasmuch  as  they  are  due  to  extension  of  the  gonorrhea  beyond  the 
urethra  proper.  They  result  usually  from  balanitis,  less  often  from 
periurethritis,  and,  like  the  balanitis  of  gonorrhea,  are  not  specific  and 
are  rarely  severe.  I  have  seen  but  one  gonorrheal  bubo  that  required 
incision. 


COMPLICATIONS  OF  ACUTE  POSTERIOR  URETHRITIS 

Prostatitis — Any  inflammation  of  the  prostate  short  of  abscess 
adds  scarcely  any  symptoms  to  those  of  the  urethritis.  Mild  pros- 
tatitis, like  mild  posterior  urethritis,  may  give  no  sign  of  its  presence, 
while  a  more  intenseprostatitis,  accompanying  posterior  urethritis,  does 
not  alter  the  clini(iP  picture  already  described.  The  involvement  of 
the  prostate  mr.y  or  may  not  be  distinguishable  by  rectal  touch. 

Prostatic  Abscess. — In  drawing  an  arbitrary  division  between  acute 
prostatitis  and  prostatic  abscess,  it  is  wiser  to  include  with  the  latter 
all  cases  of  acute  prostatitis  of  sufficient  severity  to  cause  symptoms. 
This  for  two  reasons :  all  such  cases  do  represent  retention  of  pus  within 
the  prostate  ducts,  and  any  one  of  them  may  progress  to  unmistakable 
abscess  formation. 

To  attempt  to  draw  the  line  between  the  prostate  in  which  mac- 
roscopic suppuration  (abscess)  has  already  occurred,  and  that  in  which 
it  only  threatens,  is  impracticable. 

Symptoms.' — The  symptoms  of  prostatic  abscess  follow  one  of  three 
types,  as  follows: 

The  local  symptoms  are  accentuated.     To  the  pain  and  frequency  of 


176      ACUTE  URETHRAL  GONORRHEA  IN  THE  MALE 

urination  due  to  posterior  urethritis  is  added  a  constant  dull  or  throb- 
bing ache  inside  the  pelvis,  which  may  or  may  not  radiate  to  the  ure- 
thra, the  testicles,  the  thighs,  the  hypogastrium,  or  the  loin.  If  the  pros- 
tate is  much  enlarged  defecation  is  apt  to  be  both  painful  and  diffi- 
cult. 

Fever,  often  severe,  and  ushered  in  hy  a  chill,  is  added  to  the  afebrile 
urethral  inflammation.  But  fever  is  no  criterion  of  the  extent  or  prog- 
ress of  the  prostatic  involvement.  Absence  of  fever  is  often  noted  in 
extensive  prostatic  suppuration.^ 

Retention  of  urine  is  a  marked  feature  in  many  cases.  Partial  re- 
tention escapes  observation;  but  acute,  complete  retention,  requiring 
relief  by  the  catheter,  may  occur.  I  have  relieved  by  operation  gonor- 
rheal abscess  in  both  lobes  of  the  prostate,  the  only  symptom  of  which 
was  acute  retention  of  urine,  preceded  by  no  dysuria  and  accompanied 
by  no  fever. 

Yet  in  some  instances  dysuria,  fever,  and  retention  occur  simul- 
taneously. 

Physical  Signs.- — The  suppurating  prostate  is  always  enlarged,  usu- 
ally sensitive.  The  whole  of  one  or  both  lobes  is  involved.  The  diag- 
nosis should  be  made  long  before  either  boggy  softening  or  fluctuation 
shows  that  the  whole  of  a  lobe  has  been  transformed  into  an  abscess 
cavity. 

Course. — The  process  may  terminate  by  resolution ;  by  rupture  into 
the  periprostatic  tissue,  causing  ischiorectal  abscess,  or  into  the  urethra, 
or  the  adherent  rectum,  or  by  passing  on  to  chronic  prostatitis. 

Alexander  ^  studied  68  cases  of  gonorrheal  prostatic  abscess.  Of 
these  31  appeared  during  the  first  gonorrhea,  ST  during  relapses;  35 
caused  retention  of  urine;  22  had  burst — into  the  perineum  (16),  the 
ischiorectal  fossa  (5),  the  rectum  (1).  The  abscess  was  complicated  by 
urethral  stricture  9  times. 

If  the  pus  burrows  forward  into  the  perineum  it  may  occasion  con- 
siderable mischief,  burrowing  along  toward  the  corpus  cavernosum,  or 
even  laying  it  bare.  It  has  been  known  to  go  through  the  obturator 
foramen  (Tillaux),  and  even  to  follow  the  connective-tissue  plane  about 
the  spermatic  cord  and  to  point  in  the  inguinal  canal,  or  to  get  into 
the  space  of  Retzius,  to  appear  at  the  umbilicus,  to  pass  by  the  sciatic 
notch  (Guy on) — all  very  rare,  but  still  possible  culminations  of  neg- 
lected periprostatic  suppuration. 

Seminal  Vesiculitis. — Acute  seminal  vesiculitis,  like  acute  pros- 
tatitis, usually  gives  no  sign  of  its  presence.  If  suppuration  occurs  in 
the  vesicle  the  symptoms  are  those  of  prostatic  suppuration,  but  a  finger 
3n  the  rectum  discloses  a  tense,  sausagelike  tumor  in  the  region  of  the 

'Keyes,  New  York  Polyclinic  Journal,  1908,  xii,  Nos.  9  and  10. 
'  Ann.  of  Surg.,  1903,  ilix,  533,  563. 


COMPLICATIONS  OF  ACUTE  POSTERIOR  URETHRITIS        177 

inflamed  vesicle.  It  usually  terminates  in  resolution,  but  may  rupture 
into  the  ischiorectal  fossa,  the  rectum,  or  the  peritoneum. 

Vesiculitis  does  not  occur  without  prostatitis.  It  is  impossible  to 
differentiate  inflammation  of  the  ampulla  of  the  vas  from  vesiculitis. 

Epididymitis — See  Chapter  LIX. 

Cystitis — The  familiar  gonorrheal  trigonitis  already  described  im- 
plies some  inflammation  of  the  rest  of  the  bladder,  but  this  is  not  a 
clinical  feature  of  gonorrhea.  % 

Pyelonephritis. — This  is  an  extremely  rare  complication  of  gonor- 
rhea. It  is  best  described  in  connection  with  other  types  of  pyelo- 
nephritis. * 

Peritonitis. — Pelvic  peritonitis  is  as  rare  a  complication  of  gonor- 
rhea in  the  male  as  it  is  common  in  the  female.  Battey  ^  has  collected 
30  cases.  Thomas  ^  reports  2  more.  The  inflammation  is  due  to  vesicu- 
litis or  deferentitis.  Its  symptoms  are  the  classic  ones  of  pelvic  peri- 
tonitis. 

^  These  de  Lyon,  1901 ;  Brit.  Med.  Jour.,  April  5,  1902. 
^  North  Western  Medicine,  February,  1907. 


CHAPTER    XVIII 

COURSE  AND  COMPLICATIONS  OF  CHRONIC  URETHRAL 
GONORRHEA 

Chronic  gonorrliea  is  gonorrhea  lasting  more  than  three  months. 
The  term  is  arbitrary  and  by  no  means  strictly  accurate,  for  chronic 
gonorrhea  may  be  interrupted  by  acute  relapses  of  the  disease  without 
thereby  ceasing  to  be  chronic,  and  chronic  gonorrhea  may  begin  and 
end,  from  the  clinical  as  well  as  from  the  pathological  standpoint,  within 
the  two  months  usually  allotted  to  acute  gonorrhea. 

Course — Gonorrhea  becomes  chronic  because  the  urethral  lesions 
caused  by  the  gonococcus  persist.  These  lesions  may  harbor  the  gonococ- 
cus  alone,  or  in  connection  with  other  bacteria,  or  simply  other  bacteria 
without  the  gonococcus.  They  may  involve  the  anterior  or  the  posterior 
urethra  or  both.  Chronic  gonorrhea  is  therefore  to  be  subdivided  either 
as  gonococcic  and  postgonococcic  or  as  chronic  anterior  urethritis  and 
chronic  posterior  urethritis. 

The  clinical  causes  of  chronic  gonorrhea  are  not  worth  enumerating 
in  detail.  Any  interference  with  the  proper  treatment  of  acute  gon- 
orrhea may  permit  it  to  become  chronic;  in  some  instances  it  becomes 
chronic  in  spite  of  the  best  treatment. 

Varieties — Study  of  the  flora  of  chronic  gonorrhea  (p.  166)  shows 
the  rapidly  decreasing  importance  of  the  gonococcus  and  the  rapidly 
increasing  importance  of  mixed  infection  after  the  third  month  of  the 
disease.  ISTo  further  subdivision  is  possible ;  apart  from  the  gonococcus 
no  bacterium  has  shown  itself  peculiarly  virulent  in  the  male  urethra. 
JSTongonococcic  urethritis  is  usually  postgonorrheal. 

Gonococcic  chronic  urethritis  is  distinguished  clinically  by  a 
tendency  to  be  more  severe,  to  relapse  more  viciously,  to  resent  the 
trauma  of  instrumentation  and  alcohol  more  sharply  than  does  non- 
gonococcic  urethritis.  Yet  these  clinical  distinctions  are  both  vague 
and  relative.  They  have  meaning  only  to  the  expert.  A  specific 
urethritis  may  be  latent  for  months,  a  nonspecific  one  may  be  peculiarly 
virulent. 

To  distingTiish  the  symptoms  of  chronic  anterior  urethritis  from 
those  of  chronic  posterior  urethritis  is  a  necessity,  but  clinically  the  two 
usually  exist  together,  the  one  or  the  other  predominating. 

178 


CHRONIC  POSTERIOR  URETHRITIS  AND  PROSTATITIS       179 

SYMPTOMS  AND  COURSE  OF  CHRONIC  ANTERIOR 
URETHRITIS 

The  one  subjective  symptom  of  chronic  anterior  urethritis  is  a  ure- 
thral discharge,  greater  or  less  in  quantity,  purulent,  semipurulent,  or 
sticky  and  mucoidal.  Sensations  of  itching  or  pain  almost  invariably 
arise  from  posterior  urethritis  and  its  complications,  even  when  the 
sensation  appears  to  be  situated  in  the  anterior  urethra. 

But,  since  this  urethral  discharge  is  but  the  evidence  of  an  overflow 
of  pus,  the  flow  may  be  intermittent  and  months,  even  years,  may 
elapse  while  an  anterior  urethritis  continues  but  gives  no  outward 
sign ;  but  produces  only  a  little  pus  or  a  few  shreds  in  the  urine. 

The  course  of  a  chronic  anterior  urethritis  may  be  interrupted  by 
outbreaks  of  acute  infection,  either  a  relapse  or  a  new  gonorrheal  in- 
fection. Such  outbreaks  are  usually  much  less  severe  than  the  initial 
attack. 

The  only  complicolion  of  chronic  anterior  urethritis  other  than  those 
mentioned  in  the  last  chapter  is  urethral  stricture. 

Abscess  of  the  ^irethral  glands  may  remain  as  little  suppurating 
pouches.  These  may  (1)  simply  maintain  the  infection,  or  (2)  be 
palpable  as  shotty  indurations,  which  (3)  may  at  any  time  become 
acutely  inflamed  and  tender  and  even  (4)  set  up  periurethral  abscess. 

The  urinary  signs  of  chronic  anterior  urethritis  are  a  major  element 
in  diagnosis  (p.  195). 


SYMPTOMS  OF  CHRONIC  POSTERIOR  URETHRITIS  AND 

PROSTATITIS 

Chronic  posterior  urethritis  and  chronic  prostatitis  can  rarely  be 
distingTiished  from  each  other.  Indeed,  chronic  posterior  urethritis  is 
clinically  synonymous  with  chronic  follicular  prostatitis.  On  the  other 
hand,  chronic  prostatitis  may  not  be  complicated  by  chronic  urethritis  ^ 
(30  per  cent  of  280  cases  studied  by  Young). 

Hence  it  is  preferable  to  consider  chronic  posterior  urethritis  under 
the  title  of  chronic  prostatitis. 

The  symptoms  of  chronic  prostatitis  are  much  the  same  whether 
caused  by  the  gonococcus  or  not.  If  gonococcic,  the  inflammation  is 
more  likely,  either  spontaneously  or  as  the  result  of  massage  or  urethral 
instrumentation,  to  light  up  an  acute  urethritis,  while  nongonococcic 
(or  postgonococcic)  cases  sometimes  flare  uP  in  the  shape  of  vesical 
bacteriuria.  \v 

^I.  e.,  the  prostate  may  contain  pus  but  the  urine  be  free  from  pus  and  shreds. 


180  CHRONIC  URETHRAL  GONORRHEA 

Hence  it  is  clinically  preferable  to  group  all  cases  of  chronic  pros- 
tatitis, whether  gonorrheal  or  not,  under  one  head. 

"In  our  series  of  358  cases,  no  etiology  was  obtained  in  53  cases 
(14,8  per  cent)  ;  there  was  a  history  of  gonorrheal  urethritis  in  262 
(73.2  per  cent)  ;  of  masturbation  in  27  (7.5  per  cent)  ;  of  prolonged 
sexual  excitement  (without  coitus)  in  4  cases  and  withdrawal  in  3  cases 
(2  per  cent)  ;  of  descending  infection  in  3  (0.8  per  cent)  ;  of  trau- 
matism (bicycling  twice)  in  3  (0.8  per  cent)  ;  of  instrumentation  in  2 
(0.6  per  cent)  ;  of  infectious  diseases  (grippe)  in  1  case  (0.3  per  cent). 
When  gonorrhea  had  existed,  that  was  accepted  as  the  cause  of  the 
prostatitis,  although  in  some  of  these  cases  abnormal  sexual  practices 
may  have  played  an  important  role"  (Young,  Geraghty,  and  Stevens). 

The  symptoms  of  chronic  prostatitis  are  classed  by  Young  as 
urinary,  referred;,  and  sexual.^ 

The  urinary  symptoms  are : 

Urethral  discharge. 

Disturbance  of  urination. 

Mechanical  obstruction  to  urination. 
The  referred  symptoms  are: 

Keflex  pains  and  abnormal  sensations. 
The  sexual  symptoms  are : 

Disturbance  of  the  sexual  function. 

Spermatorrhea  and  prostatorrhea. 

Urethral  Discharge — Urethral  discharge  is  a  symptom  of  anterior 
urethritis.  Yet  persistent  urethral  discharge  is  the  symptom  that  usu- 
ally brings  the  victim  of  chronic  prostatitis  to  the  physician.  More- 
over, such  urethral  discharge  can  be  cured  only  by  treatment  of  the 
prostate.  In  the  average  case,  therefore,  chronic  prostatitis  is  accom- 
panied not  only  by  posterior  urethritis,  but  by  anterior  urethritis  as 
well. 

Disturbance  of  Urination — Urination  may  be  normal,  frequent, 
painful  (before  or  during  the  act),  urgent,  or  difficult.  The  stream  may 
be  slow  to  start  or  slow  to  terminate. 

ISTone  of  these  symptoms  is  absolutely  characteristic  of  prostatitis, 
nor  can  one  infer  the  pathological  process  present  from  a  consideration 
of  them. 

Obstruction  to  Urination. — Obstruction  to  urination,  though  a  rare 
result  of  chronic  prostatitis,  may,  nevertheless,  be  the  most  important 
feature  of  a  given  case.     The  obstruction  is  due  either  to  an  enlarge- 

^In  their  study  of  chronic  prostatitis,  Young,  Geraghty,  and  Stevens  have  at- 
tributed to  this  malady  certain  symptoms  (e.  g.,  renal  colic  and  pain  in  the  rectum) 
characteristic  of  vesiculitis.  For  this  reason  the  detail  of  symptoms  given  by  them 
has  not  been  precisely  followed. 


CHRONIC  POSTERIOR  URETHRITIS  AND  PROSTATITIS       181 

ment  of  the  median  isthmus  in  the  form  of  a  bar  or  to  cicatricial  con- 
traction of  the  vesico-urethral  orifice,  i.e.,  stricture  (contracture)  of 
the  neck  of  the  bladder.  The  symptoms  are  those  of  prostatism,  occur- 
ring in  a  young  person.  The  prostate  is  usually  not  enlarged,  as  felt 
from  the  rectum  (p.  289). 

Reflex  Pains  and  Abnormal  Sensations — The  abnormal  sensation 
excited  by  chronic  prostatitis  may  be  a  pain,  an  itching  or  burning 
■  sensation,  or  a  sense  of  fullness.  It  may  be  constant  or  intermittent ; 
it  is  rarely  very  severe.  It  may  or  may  not  be  excited  by  a  full  bladder 
or  by  the  passage  of  urine.  The  majority  of  patients  with  chronic 
prostatitis  suffer  little  or  no  discomfort. 

The  abnormal  sensation  is  always  referred  to  some  point  on  the  sur- 
face of  the  body.  The  sensation  may  be  felt  at  any  point  below  the 
navel,  even  as  far  away  as  the  foot.  But  the  characteristic  pains  of 
prostatitis  are  pain  in  the  back,  in  the  perineum,  above  the  pubes,  along 
the  urethra,  in  the  gToin  or  testis.  Certain  of  these  pains  merit  a  word 
of  description. 

Pain  in  the  Back. — The  pain  is  usually  in  the  upper  sacral  region, 
constant  and  aching  in  character,  uninfluenced  by  urination.  Pain  over 
the  kidneys  is  rare.    \ 

Pain  in  the  Perineum. — The  perineal  pain  is  usually  so  mild  as  to 
be  little  more  than  a  sensation.  It  may  or  may  not  be  influenced  by 
urination.  It  is  often  associated  with  a  peculiar  sense  of  fullness  in  the 
perineal  body,  or  with  a  peculiar  irritability  in  that  region,  excited  by 
continued  pressure  against  the  perineum.  The  patient  who  suffers  from 
this  symptom  cannot  sit  still  for  any  length  of  time,  though,  as  a  rule, 
he  prefers  a  hard  seat  to  a  soft  one.  He  is  debarred  from  the  theater 
and  the  church,  and  on  the  railroad  he  either  sits  obliquely  on  one  hip 
or  paces  the  aisle.        ^* 

Pain  Along  the  Urethra. — Two  spots  along  the  penile  urethra  are 
especially  subject  to  referred  prostatic  sensations.  These  are  (1)  a 
point  just  behind  the  glans  penis  and  (2)  the  penoscrotal  angle.  Many 
patients  are  obsessed  with  the  belief  that  all  their  trouble  lies  in  one 
or  other  of  these  spots,  whereas  the  sensation  there  is  a  characteristic 
sigTi  of  trouble  in  the  deep  urethra  and  prostate. 

Disturbance  of  the  Sexual  Function — Premature  and  painful  ejac- 
ulations, incomplete  or  painful  erections,  nocturnal  emissions,  and  every 
other  symptom  of  sexual  neurasthenia  occur  in  persons  whose  prostatic 
fluid  contains  more  or  less  pus.  They  are  sensory  disturbances,  due  to 
pathological  changes  in  the  verwmontanum,  the  utricle  or  the  ejacu- 
latory  ducts.  These  symptoms  are  rare  in  patients  with  severe  pros- 
tatitis. They  are  fully  as  common  in  patients  who  have  not  had  gon- 
orrhea as  in  those  who  have. 

Prostatorrhea  and  Spermatorrhea. — Like  the  functional   disturb- 


182  CHRONIC  URETHRAL  GONORRHEA 

ance  noted  in  the  preceding  paragraphs,  prostatorrhea  and  urethror- 
rhea  are  usually  functional  sexual  disturbances  only  accidentally  post- 
gonorrheal  (cf.  p.  188). 

Symptomless  Cases — It  is  not  to  be  forgotten  that  many  cases  of 
chronic  prostatitis  produce  no  sjTuptoms. 


SYMPTOMS  OF  CHRONIC  VESICULITIS 

Chronic  inflammation  of  the  seminal  vesicle  is  always  associated 
with  chronic  prostatitis.  In  the  clinical  picture  either  inflammation  may 
predominate. 

Neuralgia  of  the  Testis  and  Cord. — Xeuralgia  of  the  testis  and  sper- 
matic cord,  whether  dependent  upon  ungTatified  sexual  excitement  or 
not,  is  very  commonly  due  to  spermatocystitis,  rarely  to  prostatitis. 

Chronic  vesiculitis  exhibits  the  following  clinical  types : 

Renal  Colic — Eenal  colic  may  be  caused  by  vesiculitis  but  not  by 
prostatitis.  I  have  seen  several  instances  of  this  condition  typical  in 
every  respect  of  a  renal  colic  due  to  stone  and  requiring  morphin  for 
their  relief.  Yet  in  each  instance  the  vesicle  was  manifestly  diseased, 
pressure  upon  it  elicited  the  pain,  and  massage  relieved  it. 

Rectal  Pain.- — A  much  more  common  and  equally  characteristic 
sjTnptom  of  vesiculitis  is  pain  in  the  rectum.  It  is  felt  in  the  region 
of  the  vesicle,  high  up  in  the  rectum.  It  is  usually  intermittent,  excited 
by  defecation,  erection,  or  ejaculation,  or  it  occurs  spontaneously.  The 
spontaneous  pain  usually  occurs  at  night  quite  independently  of  any 
sexual  irritation.  It  is  griping  in  character,  lasts  only  a  few  minutes, 
recurs  at  irregular  intervals,  and  has  been  appropriately  termed  vesicu- 
lar colic. 

Frequent  Urination.— Adhesion  of  the  chronically  inflamed  vesicle 
to  the  bladder  wall  may  exceptionally  cause  frequent  and  painful 
urination. 

Painful  Testicle — This  is  usually  a  reflex  pain  from  the  corre- 
sponding vesicle  (p.  590).  /      ^      \y 

Relapsing  Epididymitis — This  is  doubtless  due,  as  Belfield  has 
suggested,  to  occlusion  of  the  ejaculatory  duct,  with  chronic  suppura- 
tion both  in  the  vesicle  and  in  the  epididymis  (p.  570). 

Sexual  Symptoms. — Those  symptoms,  enumerated  in  the  preceding 
section,  are  due  to  inflammation  in  the  region  of  the  verumontanum. 
They  are  allied  much  more  closely  to  inflammation  of  the  vesicle  than 
to  that  of  the  prostate. 

Gonorrheal  Rheumatism. — The  importance  of  seminal  vesiculitis  in 
the  etiology  of  gonorrheal  rheumatism  has  already  been  alluded  to. 

Tuller  first  suggested  that  gonorrheal  rheumatism  is  due  to  chronic 


CLINICAL  VARIETIES  OF  CHRONIC  URETHRITIS  183 

seminal  vesiculitis.  Ample  confirmation  is  afforded  by  the  observations 
of  Squier,  Young  and  others.  But  the  mathematical  relation  has  not 
been  established.  The  great  majority  of  inflamed  vesicles  result  in  no 
septic  arthritis  or  other  symptoms  of  absorption.  Moreover  a  large 
minority  of  gonorrheal  joints  are  not  cured  even  by  vesiculectomy 
(Cabot).  Yet  in  many  instances  vesiculotomy  unquestionably  results 
in  relief  of  the  joint  pains. 

Symptomless  Cases. — So  long  as  the  vesicle  is  not  distended,  and 
the  ejaculatory  duct  not  obstructed,  the  mere  presence  of  chronic  in- 
flammation in  the  organ  usually  excites  no  symptoms. 


CLINICAL  VARIETIES  OF  CHEONIC  URETHRITIS 

The  preceding  array  of  symptoms  fails  to  give  a  picture  of  chronic 
gonoiThea.  To  obtain  this  we  must  sum  up  the  clinical  types  of  the 
disease  in  a  few  brief  paragTaphs. 

All  cases  of  chronic  urethritis  may  be  classed  as  follows : 

1.  Mild  cases. 

2.  Intractable  cases. 

3.  Relapsing  cases. 

4.  Irritable  cases. 

5.  l^eurotic  cases. 

1    Mild  Cases.  1 

2.  Intractable  Cases. /"^^^^^''^^  ^^'*  ^^^^^^^  inflammations  of 
the  urethra  are  mild  in  their  symptoms,  few  of  them  are  mild  in 
responding  promptly  to  treatment. 

A  slight"  discharge  is  all  that  marks  the  usual  case.  Yet  this  dis- 
charge may  be  utterly  intractable.  Rapidly  curable  cases  are  usually 
those  in  which  the  prostate  is  neither  markedly  inflamed  nor  hyper- 
trophied,  the  inflammation  postgonococcic,  the  patient  tractable  and  in 
good  surroundings  and  health. '  Conversely,  any  complication,  especially 
severe  prostatitis,  the  presence  of  gonococci,  or  bad  general  conditions 
are  inimical  to  a  cure. 

3.  Relapsing-  Cases. — Every  case  of  chronic  urethritis  has  some 
tendency  to  relapse  after  a  cure  has  apparently  been  effected.  But  cer- 
tain urethrae  show  a  tendency  in  this  respect  little  less  than  maddening. 
Perhaps  the  patient  has  been  carried  successfully  through  an  acute  gon- 
orrhea by  repressive  treatment  when  an  unexpected  outbreak  of  the  dis- 
ease disappoints  surgeon  and  patient  alike.  Or  a  chronic  case  may  have 
gradually  yielded  to  methodical  treatment  only  to  burst  out  afresh  at 
the  slightest  provocation.  It  is  absolutely  essential  to  know,  before 
pronouncing  a  patient  cured,  that  his  urethra  and  prostate  no  longer 


184  CHRONIC  URETHRAL  GONORRHEA 

harbor  gonococci.     This  fact  ascertained,  we  may  at  least  assure  him 
against  severe  or  infectious  relapses. 

The  cause  of  relapse  is  a  collection  of  pus  in  some  gland  or  follicle. 
Its  occasion  may  be  alcohol,  sexual  excess,  a  cold  in  the  head,  or  over- 
zealous  local  treatment. 

4.  Irritable  Cases. — The  irritability  of  some  urethrae  is  such  as  to 
prohibit  local  treatment,  whether  because  of  the  pain  and  spasm  evoked, 
or  because  an  outburst  of  acute  inflammation  in  the  urethra,  the  pros- 
tate, the  vesicle,  or  the  epididymis  follows  every  instrumentation.  This 
local  irritability,  while  in  a  sense  peculiar  to  the  individual,  is  usually 
the  result  of  habitual  disregard  of  the  rules  of  prudence.  The  patient 
is  either  a  hard  drinker,  or  addicted  to  sexual  excess,  or  overworked 
and  overworried,  or — and  this  alternative  is,  unfortunately,  not  a  rare 
one — he  has  been  irritated  by  local  treatment.  An  appreciation  of 
this  fact  will  help  to  direct  the  treatment  of  such  cases. 

5.  Neurotic  Cases. — The  neuroses  are  not  always  due  to  antecedent 
gonorrhea,  and  it  is  only  exceptionally  that  one  encounters  evidence  of 
neurosis  while  the  inflammation  still  continues.  The  neurotic  taint 
adds  many  and  various  symptoms  to  those  of  the  inflammation,  and 
protracts  the  patient's  miseries  even  after  his  prostate  has  apparently 
returned  to  its  normal  state.  But  most  of  the  so-called  neuroses  are 
due  to  the  inflammation  about  the  verumontanum. 


CHAPTER   XIX 

NONGONORRHEAL  URETHRITIS 

N^ONGONOERHEAL  Urethritis  as  distinguished  from  postgonorrheal 
urethritis  may  be  classified  as  follows : 

Nonspecific  or  "simple"  urethritis. 

Tuberculous  urethritis  (p.  433). 

Traumatic  urethritis. 

ISTeoplastic  urethritis. 

Syphilitic  urethritis. 

Herpetic  and  eczematous  urethritis. 

Urethrorrhea. 

Prostatorrhea. 

Spermatorrhea. 

NONSPECIFIC  URETHRITIS 

Nonspecific  urethritis  may  be  defined  as  an  acute  urethritis  due 
neither  to  the  gonococcus  nor  to  the  tubercle  bacillus,  and  usually  ex- 
cited by  no  known  cause  other  than  sexual  excitement  or  contact. 

Under  this  caption  we  may  also  include  the  so-called  urethritis  ah 
ingestis,  and  diathetic  urethritis,  neither  of  which  seems  to  occur  in 
virgin  urethrae. 

Urethritis  ab  Ingestis. — Certain  substances  taken  into  the  stomach 
may  occasionally  produce  a  mild  urethritis.  Among  these  alcohol  holds 
a  high  rank.  Excessive  potations,  notably  of  beer  or  champagne,  or 
prolonged  excesses  of  alcohol  in  any  form,  will  occasionally,  without 
other  cause,  produce  urethral  discharge.  As  an  adjuvant  to  sexual 
excess  the  influence  of  alcohol  is  paramount,  more  ])artienlarly  if  there 
be  already  a  preexisting  patch  of  chronic  inflammation  anywhere  along 
the  urethra.  Cantharides,  arsenic,  purgative  mineral  waters,  iodid  of 
potassium,  turpentine,  asparagus,  have  all  been  accused  of  lighting  up- 
mild  urethral  inflammation,  but  the  rarity  of  such  attacks  makes  their 
consideration  trivial. 

Diathetic  Urethritis. — A  gouty  urethritis  is  accepted  in  England 
and  a  strumous  urethritis  has  been  mentioned ;  but  as  essential  mala- 
dies both  are  a  refinement  of  diagnosis.     The  gouty  old.  gentleman 

185 


186  NONGONORRHEAL  URETHRITIS 

with,  densely  acid  urine  is  more  liable  to  discharge  because  of  his  gout, 
and  treatment  of  the  latter  may  be  essential  to  his  recovery. 

There  are  also  well-observed  instances  of  the  appearance  of  a  dis- 
charge from  the  urethra  upon  the  subsidence  of  an  arthritic  eruption 
upon  the  skin,  and  Desnos  alludes  to  the  sudden  appearance  of  a  spon- 
taneous urethral  discharge  during  the  course  of  the  grip,  believing 
it  due  to  small  prostatic  abscesses  bursting  into  the  urethra.  These 
diathetic  agencies  are  then  surely  concomitant  factors,  if  not  essen- 
tial causes,  of  primary  urethral  inflammation,  yet  they  are  extremely 
rare. 

Etiology  of  Simple  Urethritis. — That  the  normal  male  urethra  is 
immune  to  infection  by  any  bacterium  except  the  gonococcus  is  almost, 
but  not  quite,  universally  true.  Most,  if  not  all,  cases  of  so-called 
simple  or  nongonorrheal  urethritis  occur  in  urethrae  damaged  by  gon- 
orrhea or  by  sexual  excesses.  Indeed,  when  the  simple  urethritis  occurs 
in  a  canal  that  has  not  previously  harbored  the  gonococcus,  its  origin 
will  usually  be  found,  not  at  the  meatus,  but  in  the  prostate  and  seminal 
vesicles — evidence  of  its  sexual  cause. 

The  bacteria  found  in  the  normal  urethra  are  those  usually  found 
in  simple  urethritis.  But  such  important  questions  as  "Is  the  bacterium 
an  etiological  factor  ?"  and  "Is  simple  urethritis  transmissible  ?"  have 
not  been  adequately  answered.  It  seems  probable  that  nongonorrheal 
urethritis  is  sometimes  transmissible.  I  have  obtained  a  streptococcus 
from  the  urethra  of  a  man  with  simple  urethritis  similar  to  that  ob- 
tained from  a  vulvar  abscess  in  his  wife.  A  few  similar  cases  have  been 
reported,  but  they  are  most  exceptional. 

In  the  opinion  of  the  laity  nonspecific  urethritis  may  be  acquired 
from  a  nongonorrheal  woman  at  or  near  the  period  of  menstruation. 
This  opinion  has  as  little  foundation  as  that  which  attributes  infectious- 
ness to  nongonococcic  leukorrhea.  The  male  who  acquires  urethritis 
from  a  menstruating  or  leukorrheic  woman  with  whom  he  has  previously 
cohabited  with  impunity  acquires  gonorrhea. 

Pathology. — The  lesion  is  a  mild  glandular  catarrh.  It  may  be 
most  marked  in  the  anterior  urethra  or  in  the  prostate  and  vesicles. 

Symptoms — Simple  urethritis  is  usually  a  very  mild  inflammation. 
There  is  little  or  no  swelling  of  the  meatus ;  the  discharge  is  mild  and 
often  only  mucopurulent ;  urination  and  erection  are  not  painful.  The 
incubation  may  be  but  a  few  hours  or  many  days.  The  inflammation 
may  last  but  a  day  or  two  or  it  may  last  many  months. 

These  facts  suggest  that  the  condition  of  the  patient's  urethra  and 
general  health  are  of  more  importance  than  the  bacteria. 

The  duration  of  the  attack  may  be  out  of  all  proportion  to  its 
severity.     I  have  known  one  to  last  several  years. 

Diagnosis. — Simple  urethritis  is  distinguished  from  gonorrhea  by 


NEOPLASTIC  URETHRITIS  187 

the  absence  of  gonococci  from  the  discharge.  The  mildness  of  the  attack 
may  be  suggestive,  but  is  not  absolute  proof. 

The  lesion  does  not  require  diagnosis  until  the  first  outbreak  of  dis- 
charge has  been  controlled  by  local  treatment.  But  then  a  complete 
diagnosis  should  be  made  by  rectal  examination  and  urethroscopy. 

Treatment. — At  the  outset  the  condition  should  be  treated  ex- 
pectantly; i.e.,  by  sandalwood  oil,  astringent  injections  and  sexual  hy- 
giene. 

Many  cases  are  thus  cured  in  a  few  days.  But  whether  cured  or 
not  at  the  end  of  a  week  or  so  the  urethra  should  be  carefully  explored 
by  sound  and  urethroscope,  the  prostate  and  vesicles  by  massage,  and 
treatment  instituted  as  for  the  cure  of  chronic  gonorrheal  urethritis. 


TRAUMATIC  URETHRITIS 

The  causes  are,  ivounds  of  the  urethra  by  instruments,  more  espe- 
cially crushing  or  bruising  injuries.  Bending  the  penis  when  erect; 
as  in  tempestuous  and  badly  directed  coitus,  may  be  followed  by  mild 
urethritis  (sometimes  ushered  in  by  hemorrhage  and  followed  by  trau- 
matic stricture). 

A  foreign  body  in  the  urethra,  such  as  retained  stone,  may  give  rise 
to  a  mild  discharge. 

"Rough  catheterism,  a  fortiori  if  the  instrument  be  dirty,  may  pro- 
duce urethritis,  and  the  suppuration  habitually  attending  instruments 
left  indwelling  in  the  urethra  is  too  well  known  to  require  more  than  a 
statement  of  the  fact. 

Caustic  injections  of  any  kind  may  excite  urethritis.  Some  ure- 
thras are  very  sensitive  to  the  irritation  of  solutions  of  corrosive  sub- 
limate and  carbolic  acid,  and  much  more  so  to  the  minutest  dilutions 
of  formalin,  all  of  which  substances,  used  as  sterilizers  of  instruments, 
sometimes  provoke  the  very  mischief  they  would  avoid. 


NEOPLASTIC  URETHRITIS 

Papillomatous  Urethritis. — The  papillomata  are  exactly  like  sub- 
preputial  warts,  varying  greatly  in  size.  Oberlaender  ^  considers  that 
papillomatous  urethritis  is  only  a  more  pronounced  stage  of  the  hyper- 
trophic urethritis  that  sometimes  follows  gonorrhea.  The  diagnosis  and 
treatment  are  urethroscopic  (p.  203). 

Other  Neoplasms. — Other  neoplasms  of  the  urethra  are  less  inti- 
mately connected  with  urethritis.     They  are  described  in  Chapter  LIL 

^"Sajous's  Annual,"  1888,  ii,  212. 


188  NONGONORRHEAL  URETHRITIS 


SYPHILITIC  URETHRITIS 

Syphilitic  chancre  not  infrequently  involves  one  lip  of  the  urinary 
meatus,  more  often  perhaps  the  entire  circumference,  stiffening  it,  thick- 
ening the  lips,  and  being  more  or  less  eroded  and  ulcerated  down  into 
the  canal  of  the  urethra.  The  discharge  in  these  cases  is  very  slight, 
but  the  sore  lasts  many  weeks.  Concomitant  symptoms — inguinal 
adenopathy,  spirochetes,  etc. — clinch  the  diagnosis.  The  urethritis  is 
only  an  epithenomenon. 

But  the  chancre  may  be  overlooked  if  it  is  situated  at  some  distance 
within  the  urethra.  The  discharge  is  then  slight,  the  incubation  period 
long  (unless,  unhappily,  there  be  double  infection).  There  may  be 
only  the  symptoms  of  stricture.  But  care  will  detect  the  enemy.  A 
hard  lump  about  the  size  of  a  pea,  may  usually  be  plainly  felt  from 
the  outside,  and  the  endoscope  clears  up  the  diagnosis  by  disclosing  a 
gray  or  livid,  bleeding  ulcer. 

I  have  also  noted  urethritis  accompanying  the  development  of  a 
patch  of  tubercular  syphilid  upon  the  outside  of  the  penis  and  disap- 
pearing under  the  use  of  mixed  antisyphilitic  medication  by  the  mouth. 
Bassereau  and  Bumstead  speak  of  a  mucopurulent  urethral  flow  coming 
on  with  the  first  appearance  or  with  a  relapse  of  secondary  syphilitic 
eruptions,  the  cause  of  which  was  the  development  of  syphilitic  mucous 
patches  upon  the  urethral  mucous  membrane.  I  have  several  times 
seen  a  patch  of  tubercular  syphilid  involve  the  urinary  ineatus  and 
occasion  a  slight  discharge.  Gummatous  ulceration  of  the  balanitic 
urethra  is  not  uncommon. 

HERPETIC  AND  ECZEMATOUS  URETHRITIS 

That  an  attack  of  oramary  vesicular  herpes  may  occur  within  the 
urethra  is  well  known,  although  not  common.  I  have  seen  a  group  or 
two  of  vesicles  outside  and  a  mild  urethral  discharge,  with  smarting  on 
urination,  coinciding  with  the  attack  and  disappearing  spontaneously 
with  it.  Alternating  attacks,  one  outside,  the  next  inside,  have  also  been 
observed.  Eczematous  subjects  sometimes  suffer  from  a  mild  discharge 
coincident  with  a  new  outcrop  of  cutaneous  eruption  upon  or  near  the 
genitals,  or  with  the  sudden  disappearance  of  the  outside  eruption. 

URETHRORRHEA 

Urethrorrhea  is  a  nonpurulent  urethral  discharge  due  to  excessive 
secretion  from  the  urethral  glands.     This  discharge  is  mucilaginous 


PROSTATORRHEA  AND  SPERMATORRHEA  189 

in  consistence,  bluish-white  in  color.  It  sticks  the  lips  of  the  meat- 
us together.  When  caught  upon  the  finger  it  strings  out  in  a  gummy 
way. 

When  abundant  it  stiffens,  but  does  not  stain  the  linen.  The  micro- 
scope shows  it  to  be  composed  of  epithelial  cells,  leukocytes,  films  of 
striated  mucus,  granular  debris,  no  pus  threads  (unless  there  be  also 
chronic  urethritis),  no  prostatic  bodies,  no  spermatozoa,  no  lecithin 
bodies,  no  Boettcher's  crystals.^ 

The  causes  of  this  affection  are  prolonged,  ungratified  sexual  desire, 
constant  impurity  of  thought,  a  sort  of  mental  masturbation  through  the 
imagination,  often  indulged  in  by  weak-minded  youths,  as  well  as  by  old 
men  who  are  regretfully  conscious  that  they  are  getting  beyond  the 
potential  stage  of  sexuality.  Another  cause  is  delayed  orgasm  during 
intercourse  or  withdrawal  before  emission.  Masturbation  if  excessive, 
or  too  much  natural  sexual  exercise  under  the  stimulus  of  mental  provo- 
cation— all  these  and  the  like,  being  a  violence  to  the  various  urethral 
mucous  glands  and  to  the  circulation  of  the  urethra  by  prolonged, 
sustained,  excessive  nervous  tension,  lead  to  passive  congestion  of  the 
urethra  and  its  glands  and  follicles,  and  thus  occasion  an  excessive 
mucous  secretion,  together  with  more  or  less  desquamation  of  pavement 
epithelium — and  this  is  the  whole  malady. 

The  beading  of  the  meatus  during  erection  is  physiological.  It  is 
equivalent  to  the  watering  of  the  mouth  when  one  is  hungry  and  smells 
appetizing   food. 

Treatment. — Urethrorrhea  may  sometimes  be  cured  by  local  treat- 
ment, i.e.,  astringent  injections,  overdilatation  or  prostatic  massage. 
But  overzealous  local  treatment  is  calculated  to  irritate,  and  any  in- 
jection may  do  as  much  harm  as  good,  notably  in  those  self-centered 
cases  where -morbid  introspection  is  the  salient  feature  of  the  malady. 
Here  anything  that  keeps  the  patient's  mind  upon  his  genitals  harms 
him,  and  any  local  treatment  may  be  mischievous. 

Indeed  true  urethrorrhea,  be  it  due  to  whatever  cause,  gets  slowly 
better  with  the  elimination  of  that  cause — be  it  lust,  masturbation, 
excess,  or  what  not — and  by  virtue  of  sexual  and  general  hygiene. 


PROSTATORRHEA  AND  SPERMATORRHEA 

Prostatorrhea  is  the  nonsexual  discharge  of  prostatic  fluid  from  the 
meatus.  Spennatorrhea  is  the  discharge  of  semen.  The  fluid  is  dis- 
charged by  the  ^ct  of  the  pelvic  muscles,  usually  during  defecaiion, 
rarely  during  urination.     It  is  impossible  to  distinguish  prostatorrhea 

^  The  fluid  must  be  examined  in  substance.  It  cannot  be  recovered  bj  the 
pipette  from  urine  since  this  dissolves  it. 


190  NONGONORRHEAL  URETHRITIS 

from  spermatorrhea  except  by  tlie  aid  of  the  microscope.  The  prostatic 
or  seminal  fluid  discharged  may  be  normal  or  purulent. 

Etiology. — These  conditions  occur  almost  exclusively  in  young 
adults.  They  signify  a  relaxation  of  the  prostatic  or  ejaculatory  ducts 
due  to  sexual  excesses  or  irregularities.  They  are  not  themselves  in- 
flammatory, though  they  may  accompany  inflammation. 

Symptoms.— The  sensible  man  pays  no  attention  to  these  discharges ; 
the  neurotic  attributes  to  them  any  symptoms  of  sexual  debility  from 
which  he  may  sufi^er. 

There  is  no  such  disease  as  spermatorrhea.  The  alleged  malady 
is  a  fetich  created  by  Lallemand;  a  fetich  to  which  its  morbid  wor- 
shipers, young  and  old,  bow  down  throughout  the  community  morn- 
ing, noon,  and  night,  offering  to  it  the  incense  of  their  distorted  erotic 
fancies. 

I  have  known  men  who  had  sexual  intercourse  nearly  every  night  for 
years,  who  had  no  single  symptom  of  any  sexual  malady,  and  surely, 
if  an  excessive  expenditure  of  seminal  fluid  were  in  itself  capable  of 
producing  symptoms,  these  individuals  should  have  shown  some  of 
them.-^ 

I  have  known  every  symptom  attributed  to  spermatorrhea  to  occur 
in  individuals  who  had  no  seminal  loss  whatsoever,  voluntary  or  invol- 
untary. 

Finally,  one  often  finds  spermatozoa  in  the  urine  of  vigorous  men, 
ignorant  of  the  fact,  perfectly  healthy  in  a  sexual  sense,  and  absolutely 
devoid  of  any  of  the  alleged  symptoms  of  the  bugbear. 

Therefore,  spermatorrhea  does  not  cause  symptoms,  does  not  inter- 
fere with  bodily  or  sexual  health,  does  not  threaten  life  or  entail  any 
consequences,  and  it  may  be  and  should  be  wholly  disregarded.  The 
self-respecting  urologist  must  give  the  lie  to  quackery  and  disabuse  the 
public  of  false  ideas  on  this  subject. 

That  the  prostate  and  vesicles  may  be  kept  empty  by  massage  is,  of 
course,  true.  But  such  treatment,  by  concentrating  the  patient's  atten- 
tion upon  his  genitals,  is  only  calculated  to  bring  him  new  misery  when, 
with  the  cessation  of  massage,  the  discharge  returns. 

The  only  cure  is  common  sense,  the  only  relief  matrimony. 

^  Let  this  not  seem  to  imply  approval  of  sucli  gross  abuse  of  the  sexual  function. 


CHAPTER    XX 

DIAGNOSIS  OF  GONORRHEAL  URETHRITIS 

There  are  two  essential  features  in  the  diagnosis  of  urethral  gon- 
orrhea.   We  must  distinguish  both  the  presence  or  absence  of  the  gono- 
coccus  and  the  distribution  of  the  urethral  lesions. 
Diagnosis  of  the  gonococcus : 

Differentiation  between  simple  urethritis  and  gonorrhea. 
Discovery  of  the  gonococcus  in  chronic  urethritis. 
Diagnosis  of  the  seat  of  the  lesion : 
In  acute  urethritis. 
In  chronic  urethritis. 
Urethroscopic  diagnosis. 

DIAGNOSIS  OF  THE  GONOCOCCUS 

.  Acute  Simple  Urethritis  and  Gonorrhea — When  a  patient  presents 
himself  complaining  of  having  contracted  a  gonorrhea,  an  inspection  of 
his  penis  will  often  confirm  or  refute  this  opinion.  If  the  lips  of  the 
meatus  are  red  and  swollen,  exuding  a  creamy  discharge,  there  can 
scarcely  be  a  doubt  of  the  specific  nature  of  the  infection.  But  unless 
the  urethral  orifice  is  greatly  sivollen — unless  there  is  ardor  and  chordee 
— an  examinxition  of  the  discharge  is  necessary  to  differentiate  true 
gonorrhea  from  simple  urethritis.  It  may  be  that  the  gonorrheal  in- 
flammation is  not  yet  well  under  way,  or  that  there  is  chronic  gonorrhea, 
of  which  this  is  an  exacerbation,  or,  on  the  other  hand,  the  whole 
matter  may  be  a  mere  simple  urethritis.  In  either  case  the  discharge 
may  be  slight  or  profuse,  watery  or  creamy.  The  microscope  and  ''the 
Gram"  are  required  for  an  immediate  decision,  to  save  the  surgeon  from 
the  possibility  of  an  erroneous  diagnosis  and  to  afford  the  patient  the 
advantages  of  immediate  local  treatment. 

I  fear  not  everyone  will  accept  the  statement  that  nongonorrheal 
urethritis  can  simulate  the  true  specific  inflammation ;  but  I  have  seen 
cases  that  went  through  a  very  fierce  attack  and  proved  exceptionally 
unmanageable,  although  the  patients  denied  any  sexual  act  for  many 
weeks  before  the  beginning  of  their  attacks,  while  repeated  microscopical 
examinations  revealed  no  gonococcus  in  the  discharge.     In  many  other 

191 


192  DIAGNOSIS  OF  GONORRHEAL  URETHRITIS 

cases  the  acuteness  of  the  onset  gave  every  promise  of  a  true  gonorrhea, 
but  the  negative  microscopic  evidence  was  confirmed  by  the  rapid  sub- 
sidence of  the  inflammation  under  a  course  of  treatment  that  never  could 
have  conquered  the  gonococcus. 

Discovery  of  the  Gonococcus  in  Chronic  Urethritis "May  I  get 

married  ?"  The  frequency  with  which  the  sufferer  from  gonorrhea 
presents  himself  with  this  question  on  his  lips  is  a  sad  commentary  upon 
the  levity  of  youth.  Yet  it  is  a  question  which  the  practitioner  is  fre- 
quently— nay,  commonly— called  upon  to  answer.  And  upon  the  cor- 
rectness of  that  answer  the  happiness  of  a  household  often  depends.  An 
error  on  the  side  of  overcaution — forbidding  a  man  to  marry  when  he 
has  a  perfect  right  to  do  so — is  only  less  heinous  from  the  patient's 
point  of  view  than  the  permission  to  marry  before  the  danger  of  in- 
fection has  passed.  On  the  one  hand  there  is  the  prospect  of  moral 
despair  for  both  parties,  on  the  other  the  certainty  of  infection  of  the 
innocent  with  all  its  train  of  physical  woes  and  the  possible  discovery  of 
the  gTiilty  partner,  with  results  that  need  not  be  dwelt  upon. 

^nd  unhappily  the  question  is  not  an  easy  one  to  answer.  So  diffi- 
cult is  it,  indeed,  that  scarcely  any  two  authorities  agree  as  to  the 
criteria  upon  which  the  answer  shall  be  based.  Against  the  genial 
vagueness  of  the  light-hearted  practitioner,  himself  a  roue,  who  pro- 
claims that  one  is  free  from  danger  as  soon  as  he  is  down  to  his  custom- 
ary morning  drop,  we  may  oppose  the  Spartan  severity  of  those  few 
authorities  who  assert  that  once  a  gonorrheic  always  a  gonorrheic,  once 
infected  always  infectious. 

The  broad-minded  adviser  will  avoid  either  extreme.  He  knows 
full  well  that  the  majority  of  men  who  have  had  gonorrhea  become 
and  remain  absolutely  sound  and  clean.  He  recognizes  also,  that  while 
most  of  those  who  exhibit  the  traditional  morning  drop  are  undoubtedly 
infectious,  there  remains  an  important  minority  even  of  these  that  can- 
not impart  its  disease,  under  whatever  stress  of  sexual  excitement. 
These  are  practical  commonplace  facts.  We  need  not  concern  ourselves 
with  those  rare  cases  of  alleged  marital  infection  ten  or  twenty  years 
after  a  cured  gonorrhea.  By  their  very  nature  such  cases  are  open  to  a 
suspicion  of  that  symptom  common  to  all  venereal  disease,  viz. :  lying ; 
and  against  them  I  can  advance  the  experience  of  thirty-five  years, 
during  which  countless  patients  have  been  advised  to  marry  by  ,my 
father  and  his  associates  with  but  a  single  error  so  far  as  I  know.  (And 
all  will  recognize  the  probability  that  such  an  error  would  rebound 
forcibly  enough  upon  its  perpetrator.)  Such  being  the  case,  I  am 
willing  to  assert  the  possibility  of  determining  the  presence  of  gono- 
cocci  in  any  given  urethra.^ 

^  While  the  diagnosis  may  thus  always  be  definite,  the  prognosis  must  remain 
indefinite.     I  can  tell  a  man  that  he  is  or  is  not  now  infectious,  but  if  he  is  now 


DIAGNOSIS  OF  THE  GONOCOCCUS  193 

When  does  the  gonorrheic  patient  cease  to  be  in  danger  of  infecting 
the  woman  with  whom  he  cohabits  ?  Not  until  the  gonococci  have  been 
entirely  eliminated  from  him.  The  gonococcus  is  the  sole  infectious 
agent.  If  it  is  present,  there  is  danger ;  if  not,  there  is  none.  But  to  find 
the  gonococcus  is  no  easy  matter.  Its  presence  may  be  suspected  on  ac- 
count of  the  symptoms  the  patient  presents — and  this  clinical  evidence 
was  all  we  had  to  go  by  until  within  a  few  years — or  it  may  be  proved 
by  the  evidence  which  bacteriology  has  at  last  provided. 

Clinical  Evidence. — The  clinical  evidence  of  the  presence  or  the 
absence  of  gonococci,  which  has  been  for  so  many  centuries  the  physi- 
cian's only  criterion,  is  overshadowed  nowadays  by  recent  advances  in 
bacteriology.  Yet  the  bacteriologist  is  by  no  means  infallible,  and  it  is 
absolutely  essential  that  the  clinical  evidence  should  accord  before  the 
laboratory  is  permitted  to  conclude  that  a  patient  is  clean. 

The  notable  clinical  evidence  of  the  presence  of  gonococci  is  pus, 
and  in  view  of  the  prevalence  of  gonorrhea  it  is  a  general  rule  that 
whenever  there  is  pus  anywhere  in  the  genital  or  tlie  urinary  tract 
the  presence  of  -gonococci  may  he  suspected,  and  conversely  when  the 
whole  tract  is  proved  free  from  pus  the  presence  of  gonococci  may  he 
denied.^ 

Clinically  speaking,  a  great  many  classes  of  cases  may  be  ruled  out 
at  once.  Thus,  gonorrhea  of  the  kidney  is  very  rare  and  never  occurs 
except  in  conjunction  with  gonorrhea  of  the  lower  urinary  passages. 
Similarly  the  history  of  suppuration  due  to  prostatism,  stone,  tubercle, 
or  tumor  is  usually  such  as  to  rule  out  gonorrhea.  The  cases  that  come 
for  diagnosis  may  be  divided  into  three  classes : 

First,  those  who,  having  had  gonorrhea,  continue  to  have  pus  in  the 
urine  or  are  subject  to  relapses  of  pyuria  or  urethral  discharge. 

Second,  those  who,  having  had  gonorrhea,  whether  they  allege  a 
continuance  of  the  discharge  or  not,  are  not  subject  to  acute  relapses,  no 
matter  how  much  sexual  and  alcoholic  dissipation  they  indulge  in. 

Third,  those  who,  after  a  gonorrhea,  have  no  longer  a  discharge  or 
any  other  symptom,  show  perfectly  sparkling  urine  and  from  whose 
prostates  and  vesicles  no  pus  can  be  expressed. 

Of  the  first  class  the  majority  are  still  infectious ;  of  the  second  class 
the  majority  are  no  longer  infectious,  while  all  who  continue  in  the  third 
class  for  a  month  are  certainly  free  from  gonococci  and  from  all  danger. 
For  these  last,  then,  the  clinical  diagnosis  suffices ;  for  the  others  there 
is  only  a  probability  from  which  the  experienced  physician  may  often 

infectious  I  cannot  tell,  with  any  certainty,  when  he  will  become  clean.  Tliat  is  a 
matter  of  relative  immunity,  severity  of  lesion,  faithfulness  to  treatment, — details 
differing  for  every  case. 

^With  the  single  exception  that  the  patient  may  liavc  just  been  iiifoctod  and 
may  still  be  in  the  incubation  period. 


194  DIAGNOSIS  OF  GONORRHEAL  URETHRITIS 

reach  an  assured  conclusion  one  waj  or  another,  but  a  probability  which 
always  deserves  to  be  confirmed  by  scientific  tests. 

The  following  points  are  also  of  assistance  in  the  clinical  diagnosis : 

The  presence  of  shreds  in  the  urine,  even  when  those  shreds  contain 
pus  cells,  is  not  probable  evidence  of  the  presence  of  gonococci  unless 
free  pus  appears  in  the  urine  from  time  to  time.  Indeed  pus  shreds 
appear  constantly  in  the  urine  of  many  men  who  never  had  gonorrhea. 

When  the  discharge  and  the  centrifuged  urinary  sediment  show  a 
preponderance  of  epithelial  over  pus  cells  gonococci  are  very  probably 
absent. 

When  the  gonorrhea  has  lasted  three  years  without  reinfection  gon- 
ococci have  doubtless  disappeared. 

Finally,  the  clinical  evidence  is  much  fortified  by  excitation  of  the 
urethra.  To  this  end  the  patient  may  be  put  through  the  following 
three  tests  at  intervals  of  forty-eight  hours :  vigorous  prostatic  and  vesic- 
ular massage,  three  glasses  of  beer,  dilatation  with  a  Kollman  dilator. 
If  these  three  tests  fail  to  excite  a  discharge  from  which  gonococci  may 
be  cultivated,  the  gonococci  have  almost  certainly  disappeared,  even  if 
the  urine  or  expressed  prostatic  secretion  continues  to  show  pus.^ 

Laboratory  Evidence. — The  consulting  urologist  is  besieged  by 
patients  who,  at  the  close  of  a  gonorrhea  (with  urethrae  more  or  less 
completely  healed) ,  are  gonococcus-f ree  as  far  as  the  complement  devia- 
tion test,  culture,  and  clinical  signs  can  prove,  and  who  yet  are  driven 
to  an  agony  of  doubt  because  they  continue  to  show  a  few  intracellular, 
Gram-negative  cocci  (degeneration  forms  of  staphylococci)  and  pus 
cells. 

The  mere  'presence  of  Gram-negative  intracellular  diplococci  in  a. 
chronic  urethritis  does  not  warrant  the  diagnosis  of  gonorrheaj  unless 
these  are  numerous  and  typical  (p.  111). 

Therefore  the  examination  of  smears  decolorized  by  the  Gram 
method  is  a  peculiarly  misleading  test  of  the  cure  of  gonorrhea,  unless 
the  examination  is  made  by  a  peculiarly  expert  bacteriologist. 

The  only  laboratory  tests  worthy  of  credence  are  the  complement 
deviation  test  and  culture.  The  practitioner  who  cannot  command  one 
or  both  of  these  must  perfect  himself  in  the  clinical  diagnosis  and  rely 
upon  this. 

The  complement  deviation  test  is  not  reliable  until  the  patient  has 
had  posterior  urethritis  at  least  two  weeks.  But  the  more  chronic 
and  the  milder  the  urethritis  the  more  reliable  is  this  test  in  comparison 
to  culture,  which  is  most  accurate  in  active,  recent  cases. 

Practical  Method. — When  the  gonococci  seem  clinically  to  have 
disappeared,  when  the  application  of  the  beer,  massage  and  dilatation 

*  Injection  of  gonococcus  vaccine  may  excite  hidden  gonococci;  but  this  test  is 
not  infallible. 


DIAGNOSIS  OF  THE  SEAT  OF  THE  LESION  195 

test  no  longer  excites  a  discharge  loaded  with  Gram-negative  intra- 
cellular diplococci,  we  apply  the  following  test : 

1.  Wait  two  weeks. 

2.  Then  apply  the  complement  deviation  test,  and 

3.  Examine  by  smear  and  culture — 

(a)  The  urethral  discharge. 

(b)  The  first  urine  passed  (centrifuged). 

(c)  The  urine  passed  after  massage  of  the  prostate  and  vesicles 

(centrifuged)    or  the   expressed   secretion   from   these 
glands. 
The  specimens  must  be  taken  directly  from  the  patient  at  the  labora- 
tory and  examined  before  they  grow  cold. 


DIAGNOSIS  OF  THE  SEAT  OF  THE  LESION 

DIAGNOSIS  OF  THE  DISTRIBUTION  OF  ACUTE  URETHRITIS 

Acute  nongonorrheal  urethritis  may  originate  either  in  the  anterior 
or  the  posterior  urethra.  The  diagnosis  of  its  origin  and  extent  is  con- 
ducted precisely  as  is  that  of  chronic  urethritis. 

Acute  gonorrheal  urethritis  always  begins  in  the  anterior  urethra. 
The  pouting  meatus  and  creamy  discharge  amply  attest  the  presence  of 
anterior  urethritis.  But  to  diagnose  the  presence  of  posterior  urethritis 
is  not  always  possible. 

//  both  the  first  and  second  flows  of  urine  are  cloudy  there  is  pos- 
terior urethritis. 

If  only  the  first  flow  is  cloudy,  there  may  he  posterior  urethritis. 
This  is  negligible  for  the  time,  but  may  cause  trouble  later  by  delaying 
the  cure;  In  other  words,  the  mere  fact  that  throughout  a  carefully  ob- 
served gonorrhea  the  second  urine  has  always  been  clear  by  no  means 
eliminates  posterior  urethritis,  and  in  the  event  of  such  a  urethritis 
becoming  chronic  the  posterior  urethra  must  not  be  neglected. 

Examination  and  massage  of  the  prostate  reveal  lesions  in  that  organ 
as  in  chronic  urethritis ;  but  in  view  of  the  freshness  of  the  infection  this 
examination  should  be  conducted  with  the  utmost  gentleness. 

DIAGNOSIS  OF  THE  DISTRIBUTION  OF  CHRONIC  URETHRITIS 

Since  it  is  not  my  custom  to  use  the  urethroscope  in  the  diagnosis  of 
gonorrhea  except  in  rebellious  and  protracted  cases,  I  prefer  to  describe 
the  routine  method  of  examination  followed  at  the  patient's  first  visit, 
leaving  the  matter  of  urethroscopic  diagnosis  for  subsequent  discus- 
sion. 

Upon  accurate  diagnosis  depends  the  patient's  prospect  of  cure,  and 


196  DIAGNOSIS  OF  GONORRHEAL  URETHRITIS 

sucli  diagnosis,  even  without  urethroscopj,  may  require  several  exam- 
inations. 

The  patient  presents  himself  with  a  history  of  chronic  or  relapsing 
urethral  discharge,  with  shreds  or  pus  in  the  urine,  or  with  various 
sexual  or  painful  symptoms. 

The  First  Examination — The  examination  for  gonococci  already 
described  takes  first  place.  The  routine  examination  of  the  lesion  is  as 
follows : 

1.  The  meatus  is  examined  for  discharge  (and  a  smear  taken  for 
microscopic  examination)  and  inflammation,  the  urethra  for  nodules  of 
periurethral  infiltration,  the  testicles  for  evidence  of  epididjTnitis. 

2.  The  patient  then  urinates  in  two  glasses,  as  described  in  Chap- 
ter II. 

3.  A  16  F.  catheter  is  introduced,  the  site  of  pain,  bleeding  or 
obstruction  noted,  residual  urine  estimated  (to  be  confirmed  by  subse- 
quent examination),  and  about  100  c.c.  of  saturated  boracic  acid  solu- 
tion injected  into  the  bladder, 

4.  Prostate  and  vesicles  are  then  massaged;  any  expressed  secre- 
tion is  caught  upon  a  slide  for  examination. 

5.  The  patient  then  empties  the  bladder  into  two  glasses,  if  no 
secretion  has  been  expressed  by  massage ;  otherwise  into  one.  If 
residual  urine  is  suspected,  this  is  verified  by  measuring  the  amount 
passed. 

From  this  examination  we  glean  the  following  diagnostic  points : 

Anterior  Urethritis. — Usually  pus  at  meatus.  Second  flow  of  urine 
clear.  No  abnormality  felt  in  prostate  or  vesicles.  Xo  pus  in  the 
secretion  expressed  from  these  organs  or  in  boracic  acid  solution. 

Posterior  Urethritis. — Xo  pus  at  meatus,  unless  there  is  anterior 
urethritis  as  well.  (Clinically  there  is  almost  always  enough  anterior 
urethritis  to  produce  a  morning  drop.)  Second  flow  of  urine  may 
be  clear  or  cloudy.  Prostate  and  vesicles  feel  normal,  but  in  the  secre- 
tion, expressed  or  centrifuged  from  silver  solution,  there  are  a  few  pus 
cells. 

Prostatitis. — Same  as  posterior  urethritis  except  that  indurations  or 
abnormalities  of  contour  are  usually  discerned  in  the  prostate,  and  the 
expressed  secretion  is  frankly  purulent.    There  may  be  residual  urine. 

Vesiculitis. — Same  as  prostatitis,  except  that  vesicles  are  distended 
or  indurated.  Just  as  there  is  always  prostatitis  with  vesiculitis,  so 
there  is  often  impalpable  vesiculitis  with  prostatitis.  The  attempt  to 
distinguish  the  expressed  secretion  of  the  two  is  likely  to  prove  mis- 
leading, for  though  a  large  part  of  the  vesicular  secretion  floats  in  urine, 
pus  from  the  vesicle,  like  pus  from  the  prostate,  sinks. 

Stricture. — Marked  stricture  obstructs  or  prevents  the  passage  of 
the  catheter.    Slight  stricture  is  not  diagnosed  until  a  subsequent  exam- 


DIAGNOSIS  OF  THE  SEAT  OF  THE  LESION  197 

ination.  Cicatricial  or  prostatic  obstruction  at  the  neck  of  the  bladder 
gives  residual  urine. 

Cystitis. — It  is  probable  that  some  inflammation  of  the  bladder,  or 
at  least  of  the  trigone,  exists  whenever  the  second  flow  of  urine  is  puru- 
lent. But  this  cystitis  is  a  negligible  quantity  that  disappears  long 
before  the  posterior  urethritis  is  cured.  Retention  cystitis  is,  of  course, 
important. 

Pyelonephritis. — The  diagnosis  of  gonorrheal  pyelonephritis  offers 
no  peculiar  difficulties  excepting  in  so  far  as  urethritis  prohibits  cystos- 
copy. The  renal  colic  due  to  vesiculitis  and  the  lumbar  pain  due  to 
epididymitis  are  distinguished  by  physical  examination. 

Object  of  This  Method  of  Examination. — The  object  of  this 
examination  is  to  obtain  the  maximum  of  information  about  the  patient 
while  doing  him  the  least  possible  harm.  By  it  the  precise  lesion  in 
the  anterior  urethra  is  not  as  accurately  determined  as  though  the 
urethroscope  were  used.  But  the  risk  of  stirring  up  a  urethra  whose 
temper  is  not  known  warrants  deferring  this  more  precise  examination 
to  a  subsequent  date  (the  following  day,  if  the  patient  cannot  be  kept 
under  observation),  but  preferably  after  a  few  days  of  treatment,  imless 
the  case  is  very  chronic  and  the  temper  of  the  urethra  has  already 
been  well  tested  by  others. 

Secondary  Examination — In  order  to  obtain  precise  information 
as  to  the  condition  of  the  anterior  urethra  one  must  use  an  exploring 
instrument.  I  usually  employ  a  26  F.  sound.  (The  meatus  may  have 
to  be  cut. )  If  this  is  grasped  there  is  stricture.  If  it  is  not  grasped  but 
brings  blood  (not  from  the  meatus)  there  is  anterior  urethritis.  The 
precise  surface  conditions  of  both  anterior  and  posterior  urethra  are 
determined  by — 

Ueetheoscopy. — See  Chapter  XXL 

The  Bulbous  Bougie.^ — The  largest  bougie  that  will  pass  the 
meatus  is  lubricated  and  passed  gently  into  the  anterior  urethra.  As 
it  advances  the  physician  notes  the  position  of  every  obstruction  and 
even  of  every  sensitive  spot  encountered.  When  it  is  just  entering  the 
bulbous  portion  of  the  canal  it  is  withdrawn  and  the  obstructions  en- 
countered verified  as  the  instrument  passes  over  them  again  on  its  way 
out.  The  bulb  is  then  carefully  examined  and  wiped  off  to  discover 
traces  of  blood  or  pus  upon  it.  It  is  then  reintroduced  rapidly  to  the 
bulbous  urethra  and,  aided  by  firm  counter-pressure  on  the  perineum, 
insinuated  into  the  membranous  urethra. 

By  this  examination  we  distinguish  any  stricture  or  erosion  in  the 
anterior  urethra  and  locate  it  with  considerable  accuracy. 

For  an  efficient  examination  the  l)iill)  must  be  2(5  F.  in  size.  Any 
meatus  too  small  to  admit  this  must  be  cut  (p.  707). 

*  This  is   an  instrument  I  do  not  employ. 


198  DIAGNOSIS  OF  GONORRHEAL  URETHRITIS 

A  26  F,  bulb  detects  infiltrations  that  do  not  perceptibly  encroach 
"upon  the  caliber  of  the  urethra.  If  the  bulb  detects  nothing  and  anterior 
urethritis  is  nevertheless  suspected,  its  presence  is  shown  by  urethroscopy. 

CoNTEA-iNDicATiONS  TO  THE  Method. — Acutc  rclapscs  or  compli- 
cations (e.  g.,  in  prostate  or  testis)  prohibit  instrumental  examination 
until  they  shall  have  passed. 

liSTFEEEXCES  Deavv^n. — The  diagnostic  horizon  is  not  limited  by 
physical  sigtis.  We  find  by  our  examination  that  the  patient  has  this, 
that,  or  the  other  lesion;  indeed,  we  usually  find  that  he  has  several 
lesions.  But  before  the  diagnosis  is  really  complete  we  must  know 
which  is  the  predominant  lesion  and  what  part  the  patient's  general 
condition  plays. 

Our  examination  reveals,  let  us  say,  prostatitis,  anterior  and  pos- 
terior urethritis.  Under  these  conditions  we  may  feel  confident  that 
one  of  these  lesions  is  more  important  than  the  others ;  is  indeed  the 
underlying  lesion  that  keeps  the  others  going.  It  may  be  that  prostatic 
massage  alone  will  cure  the  case  promptly  and  permanently.  Or  maybe 
posterior  irrigation  is  required.  Or  perhaps  any  attack  of  the  posterior 
urethra  does  harm  and  the  patient  will  recover  on  an  interior  injection. 
Or  dilatation  may  help.     Or  any  local  treatment  may  irritate. 

These  are  not  theoretic  possibilities  but  practical  facts.  Diagnosis 
of  the  lesion  is  necessary,  but  an  absolute  therapeutic  conclusion  can 
rarely  be  drawn  from  that  diagnosis.  We  must  feel  our  way  and  try 
first  one  treatment  and  then  another. 

CoisrcEKisriK^G  Sheeds. — The  purulent  urine  of  acute  urethritis  does 
not  contain  shreds,  but  as  the  inflammation  subsides  and  tends  to  be- 
come localized  little  scabs  form  upon  the  more  inflamed  areas  and  are 
washed  away  in  the  urine.  These  are  called  shreds  (Tripperfaeden). 
They  consist  of  a  mass  of  mucous  or  fibrous  matter  entangling  pus  and 
epithelial  cells.  To  the  general  practitioner  shreds  simply  mean  that 
the  general  inflammation  is  subsiding  or  has  subsided,  r  When,  day  by 
day,  the  urine  shows  less  pus  and  more  shreds,  conditions  are  improving. 
The  following  general  observations  concerning  shreds  seem  warranted : 

1.  Shreds  are  no  index  of  gonorrhea.  They  are  currently  found  in 
the  urine  passed  by  men  who  have  never  had  gonorrhea. 

2.  The  shape  and  size  of  shreds  do  not  indicate  what  part  of  the 
urethra  they  come  from.  * 

3.  Shreds  mean  chronic  localized  inflammation  of  the  urethra. 

4.  Shreds  heavy  with  pus  sink  rapidly  in  the  urine.  They  indi- 
cate relatively  active  inflammation  or  ulcer  or  stricture. 

5.  Lighter  shreds  often  testify  to  an  inflammation  so  mild  that  it 
presents  no  dangers  and  is  entirely  uninfluenced  by  treatment. 

G.  Shreds  call  for  treatment  by  dilatation  or  urethroscope  (unless 
this  irritates). 


CHAPTEK    XXI 

URETHROSCOPY 

URETHROSCOPES 

The  urethroscope  Las  not  been  as  fully  perfected  as  the  cystoscope. 
The  models  of  the  latter  in  use  today  are  practically  standardized ;  but 
the  former  will  doubtless  undergo  many  changes  for  the  better  in 
the  course  of  the  next  decade.  We  may  describe  four  types  of  urethro- 
scope. Each  of  them  may  be  employed  to  examine  the  whole  of  the 
urethra,  but  we  restrict  our  description  as  though  the  instrument  were 
employed  only  upon  that  portion  of  the  urethra  to  which  it  is  best 
suited : 

1.  The  straight  tube  with  air  distention  (for  examination  and 
treatment  of  the  anterior  urethra). 

2.  The  straight  tube  with  water  distention  (for  examination  and 
treatment  of  the  posterior  urethra). 

3.  The  Goldschmidt  or  Buerger  type  (for  examination  of  the  poste- 
rior urethra  and  treatment  of  the  anterior  or  posterior  urethra). 

4.  The  Swinburne  type   (for  treatment  of  the  verumontanum). 

THE  STRAIGHT  TUBE 

This  is  practically  the  same  instrument  as  was  used  by  Desormaux. 
The  familiar  model  consists  of  a  nickeled  tube  12  cm.  long,  at  the 
outer  end  of  which  is  attached  a  collar  whereby  it  is  manipulated,  and 
to  which  is  attached  the  source  of  light;  a  straight  obturator  fits  into 
the  instrument. 

Source  of  Light. — The  light  may  be  reflected  from  a  head  mirror ; 
or  may  be  reflected  or  thrown  directly  into  the  tube  from  an  attachment 
at  its  outer  extremity.  This  has  the  advantage  of  leaving  the  caliber 
of  the  tube  free  for  manipulations  and  minimizing  the  danger  of  in- 
fection. It  has  the  disadvantage,  however,  of  throwing  a  light  that 
is  relatively  dim.  Instruments  of  this  type  are  sold  in  this  country 
under  the  names  of  Otis  and  Young.  Internal  illumination,  as  it 
is  called,  is  derived  from  a  small  cold  Koch  lamp  which  is  inserted 
into  the  instrument  up  to  its  internal  extremity;  such  are  the  instru- 
ments of  Chetwood,  Valentine,  etc.     We  prefer  internal  illumination, 

19? 


200  URETHROSCOPY 

whose  brilliancy  more  than  makes  amends  for  the  room  which  it  oc- 
cupies. 

Uses. — This  simple  open  tube  affords  the  best  means  of  examining 
and  treating  the  anterior  urethra.  It  may  also  be  employed  in  the 
posterior  urethra,  but  is  relatively  difficult  to  introduce,  and  inefficient 
as  compared  with  the  instrument  next  described. 

The   Steaight    Tube   with   Water   Distention 

Ever  since  the  invention  of  the  urethroscope,  attempts  have  been 
made  to  use  it  in  the  posterior  urethra.  But  if  used  without  any  dis- 
tention the  edge  of  the  tube  is  likely  to  excite  bleeding  that  obscures 
the  field  of  vision  more  rapidly  than  it  can  be  wiped  off.  Hurry  Fen- 
wick,  Mark,  and  others  have  endeavored  to  overcome  this  difficulty  by 
employing  air  distention.  The  objection  to  this  is  its  danger.  Dr. 
Mark  has  reported  a  collapse  due  to  air  embolism ;  and  I  know  of  one 
death  (unreported). 

Water  distention  is  ideal.  It  washes  away  the  blood  and  distends 
the  posterior  urethra.  One  may  employ  a  wall  tank,  elevated  at  least 
three  feet  above  the  patient,  or  a  piston  syringe.  The  elbow  obturator 
devised  by  Luys  facilitates  the  introduction  of  the  tube.  By  using 
various  degTees  of  distention  as  one  withdraws  the  instrument,  the  pos- 
terior urethra  may  be  fully  examined.  For  the  anterior  urethra  this 
instrument  is  not  quite  as  satisfactory  as  the  simple  open  tube. 

The  instrument  I  employ  bears  the  name  of  Gehringer.  It  is  sup- 
plied with  internal  illumination,  irrigating  stop-cocks  and  a  tube  for 
the  admission  of  electric  wires. 

THE  FENESTRATED  URETHROSCOPE 

Goldschmidt' s  urethroscope  was  the  first  to  provide  a  practical 
means  of  examining  the  whole  posterior  urethra.  His  instrument  was 
soon  improved  upon  by  Buerger,  who,  by  means  of  a  prismatic  mirror, 
made  his  urethroscope  an  instrument  of  great  value  for  the  treatment 
of  urethral  lesions.  Although  Goldschmidt's  instrument  includes  a 
large  armamentarium  of  implements  for  the  inspection  or  cauterization 
of  cysts,  papilloma,  inflammation  of  the  glands,  and  even  prostatic 
bars,  the  instrument  has  been  but  little  used  in  this  country. 

With  Buerger's  cysto-ureihroscope  (as  it  is  called)  one  may  make 
applications  with  great  precision  to  lesions  anywhere  in  the  urethra. 
But  for  diagTiosis  the  straight  instrument  is  superior  inasmuch  as 
it  throws  the  lesions,  especially  the  papillary  ones,  into  relief;  whereas 
with  the  Buerger  instrument,  whose  line  of  vision  is  at  right  angles 
to  the  shaft,  one  may  overlook  such  lesions. 


TECHNIC  OF  URETHROSCOPY  FOR  DIAGNOSIS  201 

The  MacCarthy  urethroscope  is  an  improvement  of  Buerger's  in- 
strument. 

The  Swinburne  urethroscope  is  a  straight  open  tube,  cut  obliquely 
at  its  internal  end,  and  with  a  solid  curved  beak  to  facilitate  its  intro 
duction  into  the  posterior  urethra. 

This  is  the  ideal  instrument  for  making  applications  to  the  veni- 
montanum. 


TECHNIC  OF  URETHROSCOPY  FOR  DIAGNOSIS 

Anterior  Urethra. — The  patient  may  lie  on  his  back,  though  it  is 
usually  wiser  to  precede  or  follow  the  examination  of  the  anterior 
urethra  by  that  of  the  posterior;  and,  for  this^  it  is  more  convenient 
to  have  the  patient  in  the  usual  cystoscopy  position,  l^o  anesthesia  is 
required.  The  tube  is  lubricated,  the  glans  penis  cleaned,  the  tube 
introduced,  directed  downward  until  it  will  go  no  further,  then  it  is 
gradually  inclined  to  an  angle  of  60°  or  more.  The  operator  then 
steadies  the  tube  with  his  left  hand ;  the  forearm  steadying  itself 
against  the  patient's  body.  The  obturator  is  then  removed  with  a 
gentle  rotary  movement  to  disturb  the  tube  as  little  as  possible.  The 
source  of  illumination  is  then  affixed  and  one  looks  for  the  orifice  of 
the  membranous  urethra.  Usually  the  tube  has  not  been  bent  over  far 
enough ;  one  sees  only  the  floor  of  the  bulb.  By  rotating  the  tube  still 
further  downward  the  puckered  lumen  comes  into  view ;  then  the  tube 
is  slowly  withdrawn,  at  such  an  angle  as  to  keep  the  lumen  of  the  canal 
in  the  center  of  the  field  of  vision. 

The  tube  is  slowly  withdrawn,  all  parts  of  the  canal  being  in- 
spected as  they  pass  under  the  eye ;  blood,  pus  or  lubricant  is  mopped 
away  with  a  cotton  swab  on  a  wooden  applicator. 

ISToEMAL  Antekiok  Ukethea. — The  walls  of  the  urethra  fall  to- 
gether over  the  end  of  the  tube  to  make  a  hollow  cone.  The  mucous 
membrane  varies  in  color  from  pale  to  salmon  pink.  The  absence  of 
inflammation  is  evinced  by  the  suppleness  of  the  walls  of  the  canal 
which  fall  together  in  longitudinal  folds  from  four  to  twelve  in  number, 
radiating  from  the  center  to  the  circumference  of  the  field ;  between 
these  folds  the  pink  mucosa  is  lined  by  longitudinal  deep  red  striae. 
Upon  the  roof  of  the  urethra  (and  less  frequently  upon  its  floor)  the 
crypts  of  the  Morgagui  appear  as  deep  red  indentations  (the  normal 
ducts  of  Littre's  glands  are  invisible). 

In  the  bulb  the  lumen  of  the  urethra  fonns  a  lateral  slit;  openings 
of  Cowper's  ducts  upon  the  floor  of  the  bulb  are  usually  concealed  by  a 
fold  of  mucous  membrane. 

The  navicular  urethra  is  pale  and  rigid ;  the  lumen  is  a  vertical  slit ; 


202  URETHROSCOPY 

there  are  no  folds  or  striae;  the  opening  of  the  lacuna  magna  is  seen 
npon  the  roof. 

The  Inflamed  Anteeioe  Ukethea. — When  subacntely  inflamed  -^ 
the  surface  is  red  and  velvety.  The  gloss  and  the  brilliant  red  striae 
are  lost.  The  swelling  of  the  mucons  membrane  reduces  the  number 
of  longitudinal  folds.     Patulous  crypt  orifices  are  seen  exuding  pus. 

Mild  chronic  anterior  urethritis  (soft  infiltration)  shows  much  the 
same  picture.  The  redness  is  not  so  marked,  the  luster  of  the  surface 
may  be  increased,  but  the  striae  are  lost,  the  folds  reduced,  the  crypts 
red,  patulous,  purulent,  or  cystic. 

Severe  chronic  anterior  urethritis  (hard  infiltration)  in  which  the 
inflammatory  exudate  has  been  largely  converted  into  scar  tissue  shows 
a  gray,  eroded,  lusterless  surface  with  no  striae,  few  or  no  folds.  The 
ducts  of  Littre's  glands  may  project  as  minute  vivid  red  points  in  the 
midst  of  a  mass  of  congestion  (glandular  type)  or  these  red  spots  may  be 
absent  (dry  type).  Sclerotic  white  patches  or  stellate  white  scars  may 
appear  here  and  there. 

Posterior  Urethra. — The  cystoscopic  position  is  the  most  convenient. 
Local  anesthesia  is  quite  as  necessary  as  for  cystoscopy,  and  is  obtained 
by  the  same  methods  (page  51).  The  urethroscope  is  introduced  like 
a  cystoscope  until  its  orifice  is  in  the  bladder.  The  obturator  is  then 
withdrawn,  the  bladder  emptied,  the  attachments  for  illumination  and 
irrigation  connected,  and  the  irrigation  conducted  so  that  a  gentle 
stream  of  water  is  constantly  flowing  into  the  instrument.  This  is 
withdrawn  in  the  long  axis  of  the  patient's  body  until  the  bladder  neck 
comes   into  view. 

The  ISToEMAL  Postekioe  TJeethra. — The  normal  bladder  neck  ap- 
pears as  an  irregularly  rounded  orifice,  the  edges  of  which  consist  of  a 
series  of  folds  over  which  course  a  number  of  irregular  blood  vessels. 
As  the  tube  is  gradually  withdrawn  the  walls  of  the  posterior  urethra 
appear  in  the  field  of  vision,  but  do  not  close  the  canal  or  hide  the 
opening  of  the  bladder  neck,  until  the  tube  has  been  withdrawn  almost 
to  the  verumontanum.  Looking  close  one  may  see  the  ducts  of  the  pros- 
tatic glands  upon  the  floor  of  the  urethra  on  each  side  of  the  median  line. 
As  the  tube  is  withdrawn  a  little  further  the  verumontanum  comes 
into  view,  an  irregularly  shaped,  rather  edematous  rounded  body,  aris- 
ing from  the  floor  of  the  urethra,  and  filling  the  field. 

When  the  verumontanum  has  been  brought  fully  into  view  a  little 
variation  in  the  force  of  the  water  stream  will  wash  it  clear  of  the 
bleeding  which  is  likely  to  result  from  the  pressure  of  the  tube,  and 
will  make  the  verumontanum  bob  up  and  down,  bringing  into  view 
the  opening  of  the  sinus  pocularis.  If  the  ejaculatory  ducts  open  at 
or  near  the  edges  of  the  sinus  these  are  visible  as  depressions,  somewhat 

^  Acute  urethritis  absolutely  contra-indicates  urethroscopy. 


i 


URETHROSCOPIC  TREATMENT  203 

larger  than  those  of  the  prostatic  ducts.  Immediately  in  front  of  the 
verumontanum  the  membranous  urethra  comes  into  view  as  a  more 
rigid,  very  red  mucous  membrane ;  as  the  tube  is  withdrawn  into  the 
bulbous  urethra  it  is  released  from  the  grip  of  the  sphincter  with  a 
sudden  jump. 

The  Inflamed  Postekioe  Urethra. — Inflammation  in  the  poste- 
rior urethra  may  exhibit  simply  an  excessive  tenderness  and  redness 
of  the  mucous  membrane,  with  obliteration  of  the  blood  vessels.  The 
orifices  of  the  ducts  may  be  unnaturally  prominent,  and  a  purulent 
exudate  may  perhaps  be  expressed  from  them.  Chronic  inflammation 
commonly  results  in  the  production  of  little  granulomata  which  look 
like  warts,  and  are  sometimes  spoken  of  as  polyps.  The  straight  tube 
almost  always  reveals  one  or  more  of  these.  Bright  pearly  cysts  are 
occasionally  seen. 

The  Inflamed  Verumontanum. — So  various  are  the  shapes  and 
sizes  of  the  verumontanum  that  it  is  difficult  to  describe  the  normal. 
Changes  in  the  verumontanum  are  doubtless  always  associated  with 
inflammation  of  the  sinus  pocularis  (Geraghty  and  Rytina).  Apart 
from  the  presence  of  little  granulomata,  inflammation  is  likely  to  cause 
an  enlargement  of  the  verumontanum,  irregular  in  outline.  But  so 
great  are  the  normal  variations  in  size  and  shape  of  the  verumontanum 
that  no  diagnosis  of  inflammation  can  safely  be  made  from  the  appear- 
ance of  the  verumontanum  alone,  except  by  an  expert  urethroscopist. 

Prostatism. — Urethroscopic  examination  of  the  enlarged  prostate 
reveals  the  lobes  projecting  into  the  urethra  just  as  cystoscopy  reveals 
them  projecting  into  the  bladder.  The  lumen  of  the  urethra  is  markedly 
enlarged  so  that  the  end  of  the  tube  must  be  moved  up  and  down  in  order 
to  see  the  whole  cavity ;  the  mucous  membrane  is  usually  inflamed. 

Carcinoma  of  the  Prostate. — Inasmuch  as  carcinoma  often  does 
not  invade  the  mucosa,  there  may  be  no  change  in  the  urethroscopic 
picture.  But  when  the  carcinoma  has  so  compressed  the  urethra  as  to 
cause  retention,  the  mucosa  at  the  bladder  neck  usually  appears  dark 
red,  and  the  orifice  is  likely  to  be  somewhat  irregular  in  outline ;  while 
less  often  ulcerated  and  fungated  areas  of  inflammation  may  be  seen 
projecting  into  the  bladder  neck,  or  into  the  bladder  itself. 


URETHROSCOPIC    TREATMENT 

Anterior  Urethra — Urethroscopic  treatment  of  the  anterior  urethra 
is  calculated  to  benefit  only  those  cases  that  show  distinctly  localized 
granulomata  or  suppuration.  The  unskilled  urethroscopist  always  sees 
a  few  reddened  or  infiltrated  spots  along  the  urethra ;  wastes  his  time 
in  cauterizing  or  incising  these  and  accomplishes  nothing,  for  in  most 


204  URETHROSCOPY 

cases  the  underlying  lesion  is  a  widespread  sclerosis,  to  be  influenced 
only  by  general  dilatation.  Yet  there  are  exceptional  cases :  ulcers  and 
granulomata  to  be  cured  by  cauterization  with  20  per  cent  silver  nitrate 
solution,  or  by  the  high  frequency  current ;  single  suppurating  glands 
to  be  drained  by  incision  and  healed  by  applications  of  silver  nitrate 
solution  once  a  week  or  so ;  long  para-urethral  ducts  exudating  pus  and 
requiring  that  they  be  slit  to  the  bottom  and  then  cauterized.  Yet  the 
neophyte  will  not  profit  by  attempting  this  form  of  local  treatment. 

Treatment  of  the  Posterior  Urethra.-^The  inflamed  posterior  ure- 
thra usual' y  requires  no  local  treatment  beyond  the  familiar  irrigation, 
instillation,  massage  and  dilatation.  Granulomata  may  sometimes  be 
cauterized  with  advantage.  The  high  frequency  spark  must  be  em- 
ployed for  this  purpose.  Cysts  may  be  punctured  by  the  spark  or  by 
the  knife  (but  these  treatments  often  do  the  patient  no  good) . 

Treatment  of  the  inflamed  verumontanum,  interest  in  which  was 
revived  by  Swinburne  a  decade  ago,  must  be  conducted  with  intelli- 
gence and  caution.  Geraghty  has  cured  intractable  cases  by  irrigation  of 
the  sinus  pocularis  through  a  small  catheter  with  one  per  cent  silver 
nitrate  solution.  Eytina  hopes  to  improve  drainage  by  giiillotining  the 
verumontanum  with  a  special  instrument.  Swinburne  has  had  gTeat 
success  in  control  of  pain,  and  the  cure  of  such  sexual  irregularities  as 
premature  ejaculation  and  nocturnal  emissions,  by  the  application  to 
the  verumontanum  of  20  per  cent  silver  nitrate  solution  through  his 
posterior  urethroscope.  ISTone  of  these  methods  of  treatment  should  be 
employed  upon  cases  that  can  be  cured  by  milder  means  (notably  by 
instillations),  l^one  of  them  should  be  persisted  in  if  they  prove  out- 
rageously painful.  Cauterization  should  not  be  repeated  oftener  than 
once  in  two  weeks.  Swinburne  applies  the  silver  nitrate  solution  rather 
lavishly  upon  a  swab,  and  then  neutralizes  it  with  salt  solution.  I 
prefer  to  use  a  swab  only  slightly  moistened  with  the  silver  nitrate  solu- 
tion, or  to  use  the  solid  stick.  I  also  employ  very  sparingly  liquor 
hydrargyri  nitratis  pure  or  in  50  per  cent  solution.  Irrigation  of  the 
sinus  pocularis  is  most  likely  to  be  beneficial  in  cases  characterized  by 
painful  emissions.  But  the  whole  subject  is  as  yet  obscure.  Cases  that 
one  would  expect  to  help  often  resist  treatment;  while  unpromising 
ones  sometimes  improve  rapidly. 


CHAPTER  XXII 

METHODS  AND  DRUGS  EMPLOYED  FOR  THE  LOCAL  TREATMENT 

OF  URETHRITIS 

Local  treatment  of  tlie  urethra  is  administered  in  the  following 
ways: 

Injection  with  small  piston  syringe. 
Forced  irrigation  with  piston  syringe. 
Forced  irrigation  with  wall  tank. 
Catheter  irrigation. 
Instillation  of  fluids. 
Instillation  of  ointments. 
Urethroscopic  applications. 
Rectal  massage. 
Rectal  irrigation. 


METHODS  EMPLOYED  ^ 

Preliminary. — The  patient  should  empty  his  bladder,  if  he  can, 
immediately  before  any  treatment  is  applied  to  the  urethra. 

INJECTION 

The  instrument  employed  is  a  two  dram  glass  or  hard  rubber  syringe. 
The  tip  may  be  of  soft  rubber  and  should  be  blunt,  so  as  not  to  injure 
the  urethral  mucous  membrane. 

The  syringe  is  filled  and  its  nozzle  applied  within  the  lips  of  the 
meatus.  To  accomplish  this  these  lips  must  be  gently  drawn  apart,  the 
nozzle  inserted  snugly  between  them,  and  the  lips  then  carefully  pressed 
against  the  syringe,  while  the  injection  is  made  by  slowly  depressing  the 
piston. 

The  pressure  upon  the  meatus  should  be  lateral,  not  from  above 
downward.  If  the  fluid  is  to  be  retained  more  than  a  moment  the 
syringe  is  withdrawn  while  the  lateral  pressure  is  continued. 

Excepting  in  the  prophylaxis  of  gonorrhea,  there  is  never  any  reason 
to  prevent  the  solution  from  entering  the  bulbous  urethra;  no  pressure 
should  therefore  be  put  upon  the  urethra  at  the  penoscrotal  angle.     K 

205 


206 


LOCAL  TREATMENT  OF  URETHRITIS 


gently  and  intelligently  performed,  the  injection  will  never  irritate 
the  posterior  urethra  or  the  epididymis. 

In  the  first  days  of  a  gonorrhea  injections  may  he  repeated  as  often 
as  every  three  hours,  thereafter  not  oftener  than  three  or  four  times  a 
day,  and  in  chronic  gonorrhea  not  oftener  than  once  or  twice  a  day. 

Some  patients  can  voluntarily  relax  the  external  sphincter  and  per- 
mit the  injection  to  flow  into  the  posterior  urethra.  This  may  be  en- 
couraged by  massaging  the  urethra  with  one  hand  while  holding  the 
meatus  with  the  other.  But  this  practice  is  not  without  danger  and 
should  be  employed  only  in  chronic  cases. 

FORCED  IRRIGATION 


The  motive  force  is  obtained  either  from  a  large  (150  c.c.)  piston 
syringe  or  from  a  wall  tank  so  arranged  that  it  can  be  lowered  or 
raised  at  will.     The  nozzle  I  employ  on  the  syringe  is  a  soft  rubber  tip 

removed  from  a  glass  urethral 
syringe.  For  the  wall  tank,  the 
nozzle  usually  employed  is  some 
modification  of  the  Janet's  nozzle, 
shield,  and  cut-off.  One  may  use 
the  Chetwood  scissors  and  two-way 
glass  nozzle  for  irrigating  the  an- 
terior urethra,  the  Swinburne  cut- 
off and  shield  and  the  Janet  (the 
so-called  Valentine)  nozzle  for 
the  irrigation  of  the  posterior 
urethra. 

The  tank  is  more  convenient 
than  the  syringe  for  anterior  irri- 
gation. The  level  of  the  fluid  in 
the  tank  should  stand  one  to  two  feet  above  the  urethra.  For  posterior 
irrigation  either  tank  or  syringe  may  be  employed.  In  order  to  force 
the  sphincter  the  tank  must  be  raised  three  to  five  feet  above  the  urethra. 
The  sphincter  may  be  forced  more  gently  with  the  hand  syringe  ^  than 
with  the  tank.  With  it  one  appreciates  and  yields  to  the  varying  pres- 
sure of  the  sphincter,  forcing  the  fluid  vigorously  only  when  this  re- 
sistance is  overcome. 

To  irrigate  the  anterior  urethra  1,000  c.c.  is  generally  used.  This 
Is  run  in  and  out  of  the  urethra  by  alternately  approaching  the  nozzle 
and  opening  the  Swinburne  cut-off  and  removing  the  nozzle  while 
closing  the  cut-off.  The  force  of  the  inflow  is  gauged  by  the  patient's 
sensations,  which  should  not  be  painful,  and  the  sense  of  urethral  dis- 
*The  Janet,  Janet-Frank,  and  Janet-Hajden  are  the  best. 


Fig.  40.- 


-Chetwood   Irrigation. 
the  nozzle. 


Filling 


METHODS  EMPLOYED 


207 


The  shield  catches 


tention  imparted  to  the  fingers  holding  the  meatus, 
the  splashing  outflow. 

Instead  of  this 
slopping  way  of  irri- 
gation I  prefer  to 
employ  the  Chetwood 
scissors  shut-off  and 
two-way  nozzle. 

The  nozzle  and 
scissors  are  attached 
and  the  instrument 
filled  in  the  manner 
shown  in  Fig.  40. 
The  nozzle  is  then 
applied  to  the  meatus 
(Fig.    41)    and    the 

scissors  alternately  opened  and  shut,  permitting  intermittent  irrigation 
of  the  canal. 


Fig.  41. — Chetwood  Irrigation.     Inserting  the  nozzle. 


CATHETER  IREIGATION 

The  catheter  is  introduced  as  described  in  Chapter  IV.  If  the  an- 
terior urethra  is  to  be  irrigated  the  catheter  should  be  not  larger  than 
15  F.  and  should  be  introduced  (about  12  cm.)  into  the  bulbous  urethra. 

If  the  posterior  urethra  is  to  be  irrigated  the  catheter  (16  to  18  F.) 
should  be  introduced  until  its  eye  enters  the  bladder  and  a  few  drops  of 
water  flow  away.  As  soon  as  the  bladder  has  thus  been  drained  the 
catheter  is  withdrawn  1  to  2  cm.  into  the  posterior  urethra.  The  fluid 
is  then  introduced  by  tank  or  syringe.  If  the  patient  can  empty  his 
bladder  the  catheter  is  then  withdrawn  and  the  fluid  urinated  out.  If 
there  is  retention  the  fluid  must  be  withdrawn  b^^  pushing  the  catheter 
back  into  the  bladder.  If  the  retention  is  slight  either  method  may  be 
followed. 

INSTILLATION 

The  Keyes  or  the  Guyon  instillator  may  be  employed  for  fluids; 
only  the  former  can  be  used  with  ointments.  The  object  of  instillation 
is  to  place  upon  a  given  portion  of  the  urethra  a  few  drops  of  a  solution 
so  concentrated  that  it  could  not  be  used  over  an  extended  area  or  in 
large  quantity. 

The  instillator  is  introduced  like  a  sound  or  a  woven  catheter.  Inas- 
much as  the  instillation  is  usually  intended  for  the  prostatic  or  the 
membranous  urethra,  one  should  have  a  clear  idea  of  the  precise 
position  of  the  instrument  as  its  tip  enters  the  posterior  urethra.     The 


208 


METHODS  EMPLOYED  209 

jump  as  it  passes  the  external  sphincter  is  often  quite  palpable ;  but  m 
case  of  doubt  one  may  always  feel  confident  that  when  the  instrument 
has  reached  a  point  in  the  urethra  where  its  shaft  rests  without  pres- 
sure at  any  angle  between  the  perpendicular  and  the  patient's  feet,  its 
point  is  in  the  membranous  urethra  (Figs.  42,  43).  Beyond  this  the 
instrument  should  not  be  introduced.  The  fluid  injected  will  bathe 
the  whole  deep  urefchra. 

In  order  to  instill  an  ointment  I  employ  a  screw-piston  syringe 
screwed  to  the  Keyes  instillator.  The  syringe  must  be  taken  apart  for 
filling.  I  see  no  peculiar  virtue  in  any  of  the  numerous  ointment  ap- 
plicators that  are  devised  from  time  to  time. 

URETHROSCOPIC    APPLICATIONS 

For  urethroscopic  applications  see  p.  203. 

RECTAL  MEDICATION 

On  account  of  its  proximity  to  the  posterior  urethra,  the  rectum  has 
always  been  a  favored  receptacle  for  drugs  intended  to  benefit  the  uri- 
nary canal,  especially  when  that  channel  was  too  acutely  inflamed  to 
permit  local  applications  directly  to  it. 

Opium  and  antipyrin  to  relieve  pain,  and  ichthyol  and  iodoform  to 
reduce  inflammation,  are  the  drugs  in  vogTie.  I  have  had  no  luck  with 
any  of  them.  Opium  is  more  efficient  when  given  by  mouth  or  by 
hypodermic,  and  rectal  irrigations  of  hot  and  cold  water  have  proven 
much  more  efficacious  than  any  chemical  medication  by  this  route, 
while  massage,  if  permissible,  is  more  efficacious  still. 

Massage. — The  way  to  examine  the  prostate  and  seminal  vesicles  by 
rectal  touch  has  been  described  in  Chapter  I.  Massage  of  these  organs, 
to  be  intelligent,  requires  familiarity  with  their  normal  contour.  The 
technic  of  massage  is  described  on  p.  242. 

Antisepsis. — Inasmuch  as  the  prostate  and  vesicles  may  contain 
gonococci,  the  extension  of  which  into  the  urethra  is  quite  likely  to  set 
up  acute  urethritis,  or  other  bacteria  that  may  cause  a  milder  infection, 
as  a  general  rule  the  urethra  should  be  flushed  with  some  antiseptic 
after  massage.  The  easiest  way  to  accomplish  this  is  by  filling  the 
bladder  with  potassium  permanganate  (1:3,000)  or  silver  nitrate 
(1 :  5,000)  before  the  massage,  and  instructing  the  patient  to  emit  this 
afterwards.     Instillation  of  silver  salts  may  also  be  employed. 

If  the  temper  of  the  urethra  is  well  known  the  antisepsis  may  bo 
omitted  in  certain  cases.  It  is  then  better  to  have  the  patient  retain 
some  urine  with  which  to  flush  the  canal  after  massage. 

Irrigation. — Eectal  irrigation  may  be  given  either  by  a  closed  tube, 


210 


LOCAL  TKEATMEXT  OF  URETHRITIS 


the  psjcliropliore,  tliroiigli  wliicli  the  water  flows  in  and  out,  or  by  a 
donble-CTirrent  tube.  The  former  is  a  much  neater  instrument  to  use, 
but  it  does  not  impart  so  much  heat  (or  cold)  to  the  patient  as  does  the 
double-current  tube. 

If  no  double-current  tube  is  to  be  had.  Tuttle's  apparatus  mar  be 
employed.  It  consists  of  two  large  soft-rubber  .catheters,  bound  or  sewed 
together,  side  bv  side.  The  water  flows  in  through  one,  out  through  the 
other.     When  the  outlet  is  plugged  with  feces,  the  current  is  reversed. 

Of  the  special 
tubes,  I  find  Chet- 
wood's  model 
(Fig.  44)  more 
convenient  than 
those  of  Kemp  or 
Tuttle. 

The  patient 
fills  a  two-quart 
douche  bag,  at- 
taches it  to  the 
tube,  hangs  the 
bag  so  that  its  elevation  above  the  outflow  shall  be  about  two  feet, 
and  greases  the  tube  with  vaselin.  He  then  seats  himself  toward 
the  back  of  a  privy  seat,  leans  back  against  the  wall,  opens  the  cut- 
off of  the  douche  bag  until  the  water  flows  warm  through  the  tube, 
and  then  inserts  the  tube  into  the  rectum  for  about  half  its  length. 
He  then  tunas  the  water  on,  and  it  flows  into  the  rectum.  If  it  does 
not  return  through  the  outflow,  he  stops  the  inflow  as  soon  as  the  rectum 
feels  full,  pokes  about  with  the  tube  until  a  gush  of  water  announces 
that  it  is  in  the  right  position,  then  turns  the  water  on  again.  It  often 
takes  from  four  to  eight  attempts  before  the  patient  learns  to  do  the  trick 
neatly. 

The  douche  is  usually  employed  once  a  day.  The  fluid  is  water  at 
a  temperature  of  120°-130°  F.  (as  hot  as  the  finger  can  bearj.  Ex- 
ceptionally, cold  water  (50°  F.)  works  better  than  hot. 


Fig.  44. — Chetwood's  Tube  for  Rectal  Irrigation. 


SOLUTIONS  EMPLOYED 


All  solutions  to  be  employed  in  the  urethra  or  bladder  should  be 
made  freshly  with  boiled  water  in  the  manner  described  in  Chapter  III. 
,'  The  following  list  represents  the  solutions  usually  employed,  the 
form  in  which  they  are  most  conveniently  kept,  and  the  strength  in 
which  they  are  usually  dissolved.  The  list  might  be  doubled  or  trebled 
■^'ithout  being  exhaustive.     The  remedies  are  classified  in   a  purely 


SOLUTIONS  EMPLOYED 


211 


arbitrary  way.     Manufacturers'  claims  as  to  silver  content  of  the  or- 
ganic compounds  are  disregarded  as  being  of  no  clinical  importance. 


Name. 


Argyrol 

Protargol 

Albargin 

Potass,  permang 

Silver  nitrate 

Silver  permang 

Hg.  oxycyanid 

Zinc  sulphate 

Zinc  acetat 

Zinc  permang 

Copper    sulphate 

Vegetable    astringents 
Ointments     and    bou- 


gies. 


Form. 


Crystals 

0.5  gm.  powders.  . 
0.2  gm.  tablets. .  .  . 

1  gr.  tablets 

10%  sol 

see  text 

0.25  gm.  powders. 

1%  sol 

see  text 

1%  sol 

]0%  sol 

1 

[  see  text 

J 


Injection. 


5-20%  ^ 
0.25-1%  1 
0.1-1%  1 


0.2-0.5% 


Irrigation. 


3    -10% 

0.1-0.5% 

0.05-0.2% 

0.01-0.05% 

0.01-0.02% 


0.01-0.05% 
0.1-0.5% 


0.05-0.2% 
0.5-4%o 


Instillatiou 

10-.'50% 
1-5% 
1-5% 

o.ili6% 


0.5-5% 


^  Must  be  retained  three  to  ten  minutes  in  the  urethra. 


First  and  foremost,  let  us  condemn  the  use  of  any  local  anesthetic  as 
a  preliminary  to  urethral  injection  in  acute  gonorrhea.  This  masking 
of  the  natural  irritative  reaction  is  an  unwarranted  and  dangerous 
procedure. 

THE  ORGANIC  SILVER  SALTS 

War  still  rages  as  to  the  relative  value  of  the  organic  salts  of  silver. 
Thus  Marshall  and  ISTeave/  experimenting  upon  the  staphylococcus- 
pyogenes  aureus,  showed  that  whereas  the  majority  of  silver  salts  ex- 
perimented with  were  powerfully  bactericidal,  argyrol  showed  no  such 
effect.  Cragin,  comparing  the  effects  of  silver  nitrate,  protargol,  and 
argyrol  on  streptococcus,  staphylococcus  pyogenes  aureus,  and  gono- 
coccus,  showed  both  the  latter  to  be  markedly  inefficient  except  against 
the  gonococcus,  which  was  killed  in  thirty  seconds  by  5  per  cent  pro- 
targol and  20  per  cent  argyrol,  in  three  minutes  by  2  per  cent,  and 
in  twelve  minutes  by  1  per  cent  protargol,  in  twenty  minutes  by  10  per 
cent  argyrol.  Burnett,^  experimenting  on  dogs,  found  that  neither 
argyrol  nor  silver  nitrate  showed  any  power  to  penetrate  tlie  urethral 
mucous  membrane.  The  report  of  Puckner  ^  and  its  discussion  ex- 
emplifies the  impracticability  of  classifying  these  salts  by  any  laboratory 
standard. 

The  only  standard  is  that  of  the  clinic.     The  clinic  decides  that  tl 
organic  silver  salts  are,  by  virtue  of  their  power  to  desti'oy  gonococci 

^  Brit.  Med.  Jour.,  August  1,  1906. 

"Am.  Assoc,  of  G.-U.  Surgeons,  1903. 

^  Jour.  Amer.  Med.  Assn.,  October  20,  1906. 


at  TliP 
si  a/c 


\1 


\ 


212  LOCAL  TREATMENT  OF  URETHRITIS 

their  relative  lack  of  irritation  to  the  urethral  mucous  membrane,  the 
best  remedies  against  acute  gonorrhea,  and  useful  in  chronic  gonorrhea 
in  proportion  as  the  urethra  is  hypersensitive  and  irritable  to  other 
remedies.  But  in  nongonorrheal  or  postgonorrheal  urethritis,  acute  or 
chronic,  the  organic  silver  salts  are  all  but  useless. 

Argyrol — Argyrol  is  the  least  irritating  of  these  remedies,  and  is 
accordingly  the  most  useful  in  acute  gonorrhea.  Yet  even  argyrol 
may  irritate.  I  have  seen  three  patients  v^ho  could  not  employ  it,  and 
two  others  with  prostatic  abscess  due  to  its  intemperate  use.  Yet 
argyrol  is  so  filthy  that  one  gladly  employs  one  of  the  other  salts  in  its 
stead  as  soon  as  the  urethra  will  permit.  The  stains  of  argyrol  may  be 
removed  by  immediate  washing  or  by  prolonged  soaking  in  1 :  500 
corrosive  sublimate  solution. 

Protargol. — This  is  fully  as  efficient  as  argyrol,  but,  in  efficient 
strenglh,  more  irritating. 

Albargin — Albargin  is  efficient,  but  somewhat  more  irritating  than 
protargol. 

ASTRINGENT  ANTISEPTIC  INORGANIC  COMPOUNDS 

The  above  clumsy  title  best  describes  a  group  of  drugs  that  vary 
widely  in  usefulness  and  antiseptic  power,  but  possess  the  common  prop- 
erty of  healing  the  inflamed  urethra — a  property  only  inadequately  ex- 
pressed by  the  word  "astringent." 

Astringent  properties,  in  the  chemical  sense,  are  claimed  for  the 
organic  silver  compounds ;  but  these  exhibit  very  faint  healing  power 
when  applied  to  the  urethra. 

Potassium  Permanganate.— For  the  irrigation  treatment  of  acute 
gonorrhea  its  virtues  are  exceeded  only  by  those  of  the  organic  silver 
salts.  It  is  our  best  remedy  to  hasten  the  cure  of  an  active  chronic 
urethritis.  It  equals  nitrate  of  silver  as  a  preventive  of  infection 
when  sounds  are  passed  or  the  prostate  rubbed,  as  well  as  in  the  treat- 
ment of  nonspecific  and  chronic  urethritis.  Yet  it  has  its  limitations. 
It  achieves  the  best  results  when  employed  in  weak  (1:3,000  to 
1:8,000)  solutions  and  in  large  quantity,  as  an  irrigation.  As  an 
injection  for  the  anterior  urethra  it  is  distinctly  inferior  to  many 
other  drugs.  In  chronic  urethritis  that  is  almost  healed  it  is  inferior 
to  silver  nitrate  instillation. 

The  statement  often  made,  that  while  gonococci  are  present  in  the 
urethra  silver  salts  should  be  employed,  and  after  they  have  disap- 
peared permanganate  resorted  to,  is  a  misleading  half  truth.  The  or- 
ganic silver  salts  are,  it  is  true,  pre-eminent  as  slayers  of  the  gonococcus, 
but  the  inorganic  silver  nitrate  and  potassium  permanganate  are  useful 
for  all  sorts  of  urethritis,  except  the  most  acute,  whether  gonococci  be 
present  or  not. 


SOLUTIONS  EMPLOYED  213 

Silver  Nitrate. — On  the  general  utility  list  silver  nitrate  stands 
equal  to  potassium  permanganate.  It  has  not  served  me  well  in 
the  abortive  treatment,  and  no  one  now  uses  it  in  advancing  acute 
gonorrhea,  excepting  as  an  instillation  for  hyperacute  posterior  ure- 
thritis. 

It  is  useless  for  anterior  urethral  irrigation  or  injection.  But  for 
posterior  irrigation  it  is  as  efficient  as  permanganate.  Moreover,  for 
instillation  and  urethroscopic  application  silver  nitrate  is  used  almost 
exclusively. 

The  pain  excited  by  instillations  of  silver  nitrate  varies  within  the 
widest  limits.  Many  a  patient  after  receiving  one  instillation  of 
1 :  1,000  silver  nitrate  solution  will  never  take  another.  Yet  this  is 
the  strength  at  which  we  usually  begin,  and  some  patients  grow  so  ac- 
customed to  it  that  the  strength  may  be  increased  to  as  high  as  10 
per  cent. 

Silver  Permanganate — This  salt  is  made  by  adding  silver  nitrate 
to  potassium  permanganate.  To  500  c.c.  of  1 :  8,000  solution  of 
the  latter  I  usually  add  from  six  to  ten  drops  (minims)  of  a  10  per  cent 
solution  of  the  former. 

I  have  found  it  useful  only  as  a  posterior  irrigation  in  chronic  cases, 
as  an  alternative  for  either  of  its  components  alone. 

Mercury  Oxycyanid. — The  cyanate  or  oxycyanid  of  mercury  is 
highly  spoken  of  by  European  writers  for  the  treatment  of  nongonor- 
rheal  urethritis.  I  have  repeatedly  tried  it  and  found  it  relatively 
irritating  and  inefficient. 

The  Zinc  Salts. — The  zinc  salts  have  been  little  used  except  as  in- 
jections for  the  control  of  chronic  anterior  urethral  discharges.  (Yet 
zinc  sulphate,  in  5  per  cent  solution,  makes  an  adequate  bladder  irri- 
gation.) They  rarely  cure,  but  they  control  the  discharge  better  than 
any  other  remedy  and  are  thus  of  great  assistance  by  the  encourage- 
ment and  sense  of  cleanliness  they  impart  to  the  patient  (but  not,  it  is  to 
be  hoped,  to  his  physician),  while  giving  nature  and  the  more  efficacious 
local  treatments  time  to  effect  a  cure. 

Zinc  Sulphate  is  the  most  popular  of  these  salts.  It  is  usually  em- 
ployed in  a  1  per  cent  solution  or  even  stronger,  though  I  fancy  it  is  as 
efficacious  in  much  greater  dilution. 

Zinc  Acetate  is  more  efficacious.  I  employ  the  following  formula 
almost  without  variation.  The  combination  throws  down  an  insoluble 
zinc  sulphate  which  helps  to  retain  the  acetate  in  the  urethra. 

^    Zinci  sulph 00.2  gm.  gr.  iij ; 

Liq.  plumbi  subacetat.  dil.  .  .ad  100.0  c.c.  §  ii.l- 

M.  Shake, 

S.  Inject  b.i.d. 


214  LOCAL  TREATMENT  OF  URETHRITIS 

Zinc  Permanganate  is  a  hygroscopic  salt  and  is,  therefore,  best 
kept  in  solution.  At  a  strength  of  1 :  2,000  it  is  extremely  efficacious ; 
sometimes  more  so  than  the  acetate.  It  is  possible,  but  apparently 
unnecessary,  to  use  it  in  much  stronger  solution. 

Other  Astringents. — The  following  composite  preparations  are 
recommended  by  various  authors : 

I^   Zinci  sulphatis gr.  xv ; 

Plumbi   acetatis gr.  xx ; 

Tr.  opii.  1  __   r^   .. 

m       \    1         f- aa  o  11 ; 

Tr.  catechu    J  ■' 

Aquae    ad  §  vj. 

(Brou.) 

R   Zinci  sulphatis.  "1  __  .        j  .. 

Pulv.alum  I aagr.jv.adgr.xij; 

Acid  carbolic    g^-  j^'} 

Aquae    B  jv. 

(Ultzmann.) 

I^   Zinci  sulphatis .  gr.  xij  ; 

Resorcin    gr.  xxjv ; 

Aquae §  jv. 

(Morton.) 

I^    Cupri  sulphatis    0.20  gr.  iij  ; 

Alum  crud 1.00  gr.  xv ; 

Aquae    200.00  §  vij. 

(Kreissl.) 

VEGETABLE  ASTRINGENTS 

The  vegetable  astringents  are  legion.  Almost  every  known  fluid, 
from  hot  and  cold  water  to  tea  and  claret,  has  been  employed  in  the 
course  of  a  gonorrhea  that  terminated  in  a  cure.  These  remedies  are 
only  employed  as  injections  in  chronic  or  nongonorrheal  urethritis  as 
substitutes  for  the  zinc  salts.    I  am  not  enthusiastic  over  any  of  them. 

The  following  are  advised: 

I^   Extr.  hydrast.  fl.^  ] 

Bismuth  subcarb.  [ aa  o  v j ; 


Boroglycerid  (25  per  cent) 

Aquae  destill ad  5  vj. 

(White  and  Martin.) 

^  The   ' '  colorless ' '   preparation   has   been    shown    to   be    but   a   dilution    of   the 
colored  drug.    Hydrastis  leaves  an  indelible  yellow  stain  on  linen. 


SOLUTIONS  EMPLOYED  215 

!l^   le.hthyol .    gr.  xx  to  o  jss ; 

Aquae q.s.  ad  §  jv. 

(Bauniann.) 

!l^   Berberine  hydrochlorate    gr.  v ; 

Aquae    §  viij. 

(Belfield.) 

OINTMENTS  ANT>  DRUGS 

The  application  of  urethral  medication  in  an  oily  or  greasy  form 
has  seemed  to  many  an  ideal  way  of  treating  chronic  urethritis.  Re- 
sults have  generally  fallen  below  expectations.  I  have  derived  no  ad- 
vantage either  from  ointments  or  soluble  bougies.  Young/  who  has 
reviewed  the  subject  exhaustively,  employs  lanolin  as  excipient  and  uses 
the  following  formulae : 

For  cases  with  marked  epithelial  changes,  salicylate  acid  (0.5  to  1 
per  cent). 

For  "less  severe  cases,"  iodoform  (10  per  cent),  silver  nitrate  (1  to 
2  per  cent),  or  boric  acid  (10  per  cent). 

For  cases  with  considerable  glandular  involvement,  protargol  (2  to 
5  per  cent),  or  bichlorid  of  mercury  (1:10,000),  or  formaldehyd 
(1:5,000). 

Janet,  Caspar,  Finger,  and  Bazy  are  among  the  other  advocates  of 
the  method. 

Formulae  similar  to  the  above  are  made  up  as  suppositories,  to  be 
inserted  into  the  anterior  urethra.  I  have  not  found  them  as  useful  as 
injections. 

1  Johns  Hopkins  Hosp.  Eeports,  1906,  XIII,  115. 


CHAPTEE    XXIII 

SYSTEMIC  TREATMENT  OF  URETHRAL  GONORRHEA 

The  efficacy  of  local  treatment  in  repressing  acute  urethral  gon- 
orrhea leads  many  practitioners  to  forget  the  old  "methodic"  treatment, 
the  sole  reliance  of  our  fathers.  The  methodic,  or  systemic,  treatment 
of  acute  gonorrhea  has  indeed  been  relegated  to  second  place ;  yet  it  is 
still  important,  not  only  when  repressive  local  treatment  is  inapplicable, 
but  also  as  an  accessory  to  this  local  treatment.  The  hygienic  and 
dietetic  part  of  the  treatment  is  of  the  utmost  importance.  If  disre- 
garded, the  best  directed  efforts  may  miscarry. 

CLEANLINESS 

The  parts  should  be  washed  as  often  as  required,  soap  and  warm 
water  being  as  good  as  an  antiseptic  solution  and  more  readily  at  hand. 
The  discharge  should  be  kept  from  smearing  the  underclothing.  If  the 
foreskin  is  long,  the  glans  penis  may  be  thrust  through  a  slit  in  the 
center  of  a  small  square  of  gauze  until  the  slit  lies  snugly  behind  the 
corona  glandis ;  thus  held  in  place,  the  gauze  is  folded  forward  over  the 
glans  penis,  covered  by  replacing  the  foreskin,  and  left  puckered  up 
and  long  enough  to  protrude  in  a  bunch  in  front  of  the  preputial 
orifice.^  If  the  prepuce  is  short,  an  apron  of  old  cotton  or  linen  doubled 
may  be  fastened  to  a  string  about  the  waist  or  pinned  to  a  suspensory 
bandage,  and  the  entire  genitalia  wrapped  up  in  this;  or  one  of  the 
penis  bags  furnished  by  the  shops  may  be  employed. 

Inasmuch  as  suspension  of  the  testicles  is  advisable  as  a  preventive 
of  epididymitis,  a  "jockstrap"  should  be  worn.  This  will  act,  inci- 
dentally, as  a  bag  to  contain  the  gauze  or  cotton  garnishing  the 
meatus. 

Finally,  the  patient  must  be  told  the  danger  to  his  eyes  from  con- 
tamination with  his  urethral  pus,  and  cautioned  to  touch  the  genitals  as 
little  as  possible  and  to  wash  his  hands  thoroughly  with  soap  and  ivater 
every  time  he  has  touched  his  penis. 

The  pledget  of  absorbent  cotton,  which  is  so  efficient  when  the  discharge  is 
mild,  retains  the  more  profuse  discharge  in  contact  with  the  head  of  the  penis,  thus 
preventing  proper  drainage  of  the  inflamed  urethra. 

216 


SEXUAL  HYGIENE  217 


DIET 


The  rigorous  diet  usually  prescribed  excludes  all  alcohol,  spices, 
rich  and  indigestible  sauces  and  foods,  fruit,  coffee,  tea,  and  sparkling 
water.  I  have  found  it  of  no  benefit  to  the  patient's  urethra  to  be  so 
strict,  and  a  great  encouragement  to  his  mind  to  permit  a  greater  lati- 
tude. Alcohol,  spices,  and  condiments  must,  of  course,  be  prohibited, 
and  it  is  well  to  specify  ale,  beer,  cider,  and  ginger  ale,  besides  insisting 
that  any  substance  which  burns  the  palate  as  it  enters  the  bod}^  will  burn 
the  urethra  as  it  issues  forth  (we  speak,  of  course,  of  chemical,  not  of 
physical  heat).  Indigestion,  whether  from  overeating  or  from  indis- 
creet eating,  is  harmful,  and  acid  fruits,  especially  lemons  and  grape 
fruit,  as  well  as  asparagus,  are  apparently  irritating.  But  there  is  no 
reason  to  prohibit  these  absolutely  nor  to  prohibit  tea  or  coffee  at  all. 
I  do  not  prohibit  sparkling  waters. 


REST 

Physical  rest  is  most  important.  Were  it  possible  for  the  business 
of  the  world  to  be  transacted  with  all  the  sufferers  from  acute  gonorrhea 
in  bed,  and  were  rest  in  bed  not  the  very  worst  thing  for  the  state  of 
mind  of  these  same  sufferers,  it  would  be  wiser  to  place  them  all  upon 
their  backs.  But,  takijig  the  world  as  it  is,  the  best  plan  is  to  urge  each 
patient  to  rest  as  much  as  may  be ;  to  ride  rather  than  to  walk,  to  sit 
rather  than  to  stand.  Eailroad  and  automobile  trips  seem  to  be  a 
peculiarly  injurious  form  of  locomotion. 


SEXUAL  HYGIENE 

During  the  acute  stage  absolute  continence  is  essential,  and  this 
should  be  extended  at  least  two  weeks  after  the  cessation  of  all  discharge, 
with  the  avoidance  of  anything  liable  to  induce  sexual  excitement — asso- 
ciation with  women,  racy  books  and  pictures,  erotic  thoughts  et  id  genus 
omne. 

Such  is  the  general  rule ;  yet  I  have  known  patients  accustomed  to 
frequent  sexual  intercourse  to  be  constantly  distressed  by  painful  erec- 
tions unless  they  relieved  their  sexual  tension  by  cohabitation  (with  a 
condom).  Such  license  should  nevertheless  be  absolutely  pi'ohibited. 
Massage  of  the  prostate  and  vesicles  cannot  wholly  replace  it. 


218    SYSTEMIC  TREATMENT  OF  URETHRAL  GONORRHEA 


DILUENTS 

The  patient  should  drink  (between  meals  if  he  is  dyspeptic)  about 
eight  glasses  of  water  a  day.  Ordinary  drinking  water  suffices,  but,  if 
he  can  afford  it  and  it  does  not  prove  too  diuretic,  an  alkaline  diluent, 
such  as  Vichy  Celestins,  is  preferable. 

But  here  again  common  sense  must  temper  routine  practice.  In 
acute  gonorrheal  cystitis  and  in  very  acute  posterior  urethritis  more 
harm  may  be  done  by  the  muscular  straining  attending  the  frequent 
repetition  of  the  urinary  act  than  is  atoned  for  by  any  amount  of  dilu- 
tion of  the  urine. 

INTERNAL  MEDICATION 

The  drugs  that  may  be  effectively  exploited  to  combat  acute  urethral 
inflammation  belong  to  five  orders : 

1.  Urinary  antiseptics. 

2.  Alkalies. 

3.  Demulcents. 

4.  Anodynes. 

5.  Balsamics. 

1.     URINARY  ANTISEPTICS 

Urinary  antiseptics,  such  as  hexamethylenamin,  methylene  blue, 
salol,  benzoic  acid  and  the  benzoates,  boric  acid  and  the  borates,  have 
no  recognizable  influence  upon  urethral  inflammation.  Theoretically, 
they  ought  to  be  of  paramount  importance,  but  practically  these  sub- 
stances, so  valuable  in  suppurative  conditions  of  the  urinary  tract  above 
the  bladder,  are  useless  below  that  point,  whether  because  their  bac- 
tericidal efficiency  is  slight,  or  because  their  sojourn  in  contact  with  the 
inflamed  urethral  wall  is  limited,  or  because  the  bacteria  are  shielded 
from  the  antiseptic  action  of  the  medicated  urine  by  the  tissues  in 
which  they  lie.  The  value  of  hexamethylenamin  and  of  methylene  blue 
in  acute  gonorrhea  has  been  vaunted.  In  my  opinion  it  is  slight ;  so 
slight  that  it  does  not  deserve  consideration. 

Yet  hexamethylenamin  is  very  useful  to  protect  the  kidneys. 
It  should  be  given  whenever  there  is  an  unexplained  rise  of  temperature 
in  the  course  of  a  gonorrhea. 

2.     ALKALIES 

The  virtue  of  alkalies  in  the  treatment  of  urethral  inflammations 
depends  rather  upon  the  condition  of  the  urine  than  upon  the  grade  of 


INTERNAL  MEDICATION  219 

the  inflammation.  The  urine,  normally  acid  and  often  dense,  is,  ipso 
facto,  harmful  except  in  so  far  as  it  washes  the  urethra,  and  the  alkali 
is  negatively  a  very  good  thing,  but  good  only  when  required  to  counter- 
act acidity.  In  other  words,  there  is  no  specific  action  whatsoever  in 
the  alkalies.  They  do  not  in  the  least  control  suppuration.  If  one  had 
two  burned  hands,  and  placed  one  of  them  in  vinegar  and  water  and  the 
other  in  a  watery  solution  of  bicarbonate  of  soda,  he  would  doubtless 
prefer  the  sensations  experienced  in  the  hand  immersed  in  the  mild  al- 
kali, and  so  it  is  with  the  urethra. 

Patients  having  normally  bland,  alkaline,  dilute  urine  (and  there 
are  ma.ny  such)  stand  in  no  need  of  alkalies,  and,  indeed,  may  occasion- 
ally be  injured  by  them,  through  indigestion. 

When  the  urine  is  acid  an  alkali  is  indicated.  If  the  urine  be 
also  dense  a  diuretic  alkali  is  called  for;  if  dilute  (sp.  gr.  1.015  or  less), 
the  diuretic  quality  is  not  needed. 

Alkalies  produce  the  greatest  effect  relative  to  the  size  of  the  dose, 
if  administered  toward  the  end  of  the  second  hour  after  eating. 

Bicarbonate  of  Soda — This  is  the  mildest  of  the  alkalies.  Its  chief 
virtue  is  that  it  aids  digestion,  while  the  other  alkalies  impede  digestion 
more  or  less.  Dose,  0.50  to  1  gram.  It  is  prescribed  in  the  form  of 
tablets. 

Sweet  Spirits  of  Niter  (spts.  etheris  nitrosi). — Sweet  spirits  of  niter 
is  notable  for  its  anodyne  rather  than  its  alkaline  properties.  It  is 
chiefly  employed  for  the  slight  irritation  of  the  bladder  so  common 
in  women.     Dose:  2-6  gm.,  in  water. 

Potassium  Citrate,  Potassium  Acetate,  Liquor  Potassae. — These 
three  salts  are  employed  more  than  any  others  as  urinary  alkalinizers. 
The  citrate  is  the  most  efficient  as  an  alkali,  but  irritates  some  stomachs, 
the  liquor  the  most  anodyne,  the  acetate  the  most  diuretic.  Therefore 
the  liquor  is  most  useful  in  acute  cases,  and  the  citrate  in  chronic  cases. 
The  acetate  is  a  stronger  diuretic  than  the  citrate,  but  I  have  found 
it  also  more  irritant  to  the  stomach.  The  dose  of  each  drug  is  about 
0.5  gram  in  a  considerable  quantity  of  water.  The  disagreeable  taste 
is  well  disguised  by  syrup  of  cinnamon. 

Bromid  of  Potassium. — This  acts  as  an  alkali  and  is  sometimes  eflS- 
cient  in  controlling  the  smarting  upon  urination. 

3.     DEMULCENTS 

Demulcents  are  much  less  used  now  than  formerly,  but  may  be 
comforting  when  combined  with  an  alkali.  To  this  class  belong  flax- 
seed tea,  glim  water  and  elm-bark  water,  the  various  fluid  extracts 
made  from  buchu,  pareira  brava,  uva  ursi,  triticum  repens,  and  corn- 
silk. 


8.00-25.00  gi% 

3  ij-vj ; 

15.00-35.00  gr. 

§  ss-j ; 

[.  s.  ad  100.00             gr. 

§  iij- 

220    SYSTEMIC  TREATMENT  OF  URETHRAL  GONORRHEA 

4.  ANODYNES 

Anodynes  are  called  for  to  moderate  pain  on  urination,  and  for  this 
bromid  of  potassium  or  the  tincture  or  fluid  extract  of  hyoscyamus  gen- 
erally suffices.     A  favorite  old-fashioned  prescription  is : 

3^   Liq.   potassae    

Tr.   hyoscyami    

Syr.  cinnamon    ...... 

M. 

Sig. — Teaspoonful  in  water  two  hours  after  each  meal  (or  oftener). 

For  Intense  Chordae. — Lupulin  in  doses  of  2  to  4  grams  taken  upon 
retiring  is  sometimes  effective,  or  a  similar  dose  of  the  bromid  of  potas- 
sium. The  coal-tar  products  are  useless,  codein  feeble,  opium  risky. 
Hot  water  is  a  good  preventive,  cold  water  a  quick  relief  (as  stated  be- 
low).    The  patient  should  sleep  lightly  clad  in  a  cool  room. 

For  Painful  Urination. — The  anodyne  mixture  given  above  is  excel- 
lent. Codein  or  bromids  may  be  added  for  a  severe  case  of  acute  cys- 
titis. It  is  an  advantage  to  instruct  the  patient  suffering  from  this 
complication  not  to  empty  his  bladder  completely,  but  to  let  the  last  of 
the  urine  dribble  away  without  the  aid  of  the  distressful  piston  stroke. 
The  instruction  is  hard  to  follow,  but  it  may  afford  great  relief.  The 
uses  of  water  in  this  connection  are  mentioned  below.  The  role  of  the 
prostate  must  not  be  forgotten,  and  if  all  else  fails,  local  treatment  (p. 
235)  or  even  operation  may  be  resorted  to. 

Hot  Water  is  of  value  in  various  ways.  When  the  pain  on  urina- 
tion is  intense  it  may  be  somewhat  moderated  by  immersing  the  penis 
in  very  hot  water  and  urinating  into  it.  Prolonged  soaking  of  the  penis, 
just  before  retiring,  in  water  as  hot  as  can  be  borne,  will  often  prevent 
or  moderate  chordee  during  the  night. 

A  Hot  Hip  Bath  is  full  of  comfort  for  the  patient  with  any  form 
of  acute  prostatic,  vesical,  or  seminal  vesicular  inflammation.  Such  a 
bath  may  be  repeated  every  few  hours.  It  should  be  short,  not  lasting 
more  than  five  minutes.  The  temperature  of  the  water  at  first  should  be 
near  104°  F.,  and  after  the  patient  is  in  the  bath  more  hot  water  should 
be  added  until  the  temperature  is  as  high  as  he  can  tolerate. 

The  Hot  Eectal  Douche  (p.  209),  once  or  twice  a  day  is  even 
more  efficient. 

Iced  Water  is  useful  when  the  penis  is  erect  and  in  chordee.  The 
patient  naturally  urinates  at  once,  if  he  can,  and  then  by  pouring  iced 
water  over  his  turgid  and  unruly  member,  or  by  placing  it  alongside 
a  cold  piece  of  metal,  he  strives  to  reduce  it  to  subjection.  To  break 
a  chordee  is  to  invite  stricture. 


INTERNAL  MEDICATION  221 


5.     BALSAMICS 


Some  form  of  balsamic  should  be  administered  throughout  the  acute 
stage  of  gonorrheal  urethritis.  It  may  or  may  not  be  obviously  bene- 
ficial in  a  given  case,  but  it  is  never  harmful  if  the  single  rule  is  ob- 
served, that  the  medicine  should  never  disagree  with  the  patient's  diges- 
tion.   In  order  to  benefit  the  urethra  it  should  not  upset  the  stomach. 

The  products  of  the  synthetic  laboratory,  such  as  gonosan  (two  cap- 
sules three  times  a  day),  arrhovin  (same  dose),  or  santyl  (same  dose), 
are  perennially  hailed  as  a  prodigious  advance  over  the  old  crude  method 
of  balsamic  medication.  Careful  trial  of  the  drugs  cited  has  not  con- 
vinced me  that  they  are  any  more  or  any  less  potent  than  the  more 
familiar  drugs  contained  in  the  capsules  compounded  by  American 
firms. 

Among  the  older  balsamics  oil  of  yellow  sandalwood,  balsam  of  co- 
paiba, cubeb,  and  oil  of  wintergTeen  are  the  only  ones  of  proven  value. 
Eucalyptol,  kava-kava,  matico,  pichi,  and  many  others  are  variously 
rated,  but  are  not  generally  employed. 

If  sandalwood  oil  in  small  quantity  gives  a  man  so  severe  a  pain  in 
his  back  that  he  can  neither  exercise  nor  sleep,  and  if  copaiba  in  moder- 
ate doses  so  upsets  his  stomach  as  to  produce  nausea,  or  if  he  easily 
gets  copaibal  erythema,  he  certainly  cannot  derive  proper  advantage 
from  these  drugs,  and  it  is  folly  to  push  them.  But,  on  the  other  hand, 
when  the  balsams  agree  they  are  exceedingly  helpful,  and  their  dose 
may  be  pushed  with  advantage  up  to  the  limit  of  satisfactory  digestion. 

Sandalwood  Oil. — The  preparation  made  from  yellow  sandalwood 
is  probably  better  than  that  made  from  the  red,  but  both  have  merit. 
It  is  prescribed  after  meals  in  capsules,  containing  5  and  10  minims 
(and  in  all  sorts  of  combinations  with  other  balsams  and  with  salol, 
with  pepsin,  etc.). 

The  dose  of  sandalwood  oil  should  be  at  least  O.Y  gi-am  (10  minims) 
three  times  a  day.  (It  may  be  pushed  to  2  grams  (30  minims)  four 
times  a  day;  though  rarely  is  so  much  required.)  Even  the  lowest 
dose  sometimes  upsets  digestion  or  gives  the  distressing  pain  in  the 
hack,  which  calls  for  a  diminution  in  dose  or  a  change  of  drug. 

If  a  liquid  be  preferred  to  a  capsule  the  alkali  and  balsam  are  easily 
combined. 

I^   Potass,  citrat.  (or  hy drat.)        8.00-25.00  gm.  3  ij-vj  ; 

01.  santal ' 15.00-25.00  gm.  5  jv-vj  ; 

Syr,   acaciae    30.00  gm.  §  j ; 

Aquae  menth.  pip.  q.  s.  ad  100.00  gm.  §  iij. 

M.  Shake. 
Sig. — Teaspoonful  in  water  two  hours  after  eating. 


222    SYSTEMIC  TREATMENT  OF  URETHRAL  GONORRHEA 

Copaiba. — This  may  be  prescribed  (4  to  10  grams)  instead  of  san- 
dalwood oil  in  this  combination  late  rather  than  early  in  the  disease, 
and  fluid  extract  of  hyoscyamus  or  deodorized  tincture  of  opium  if  re- 
quired as  an  anodyne. 

This  dose  is  easier  to  take  than  the  time-honored  Lafayette  mix- 
ture— Heaven  knows  why  that  warrior  allowed  his  name  to  become 
attached  to  such  a  compound! — and  the  citrate  of  potash  seems  to  do 
better  work  than  the  niter  of  that  mixture.  Bicarbonate  of  soda  may 
substitute  the  citrate  of  potash  when  a  diuretic  effect  is  not  desired,  and 
wintergreen  or  licorice  flavors  be  substituted  for  the  mint.  Copaiba 
more  than  sandalwood  oil,  however,  demands  the  capsular  form  of  ad- 
ministration.   It  often  nauseates,  sometimes  occasions  diarrhea. 

Copaibal  erythema  consists  in  the  appearance  of  closely  aggregated, 
slightly  elevated,  itching,  red  blotches  scattered  over  the  whole  trunk. 
It  is  easily  cured  by  a  discontinuance  of  the  drug,  an  alkaline  laxative, 
a  few  warm  bicarbonate  of  soda  baths. 

Cubeb. — This  is  a  stimulant  as  well  as  a  balsamic.  It  agrees  with 
most  stomachs,  but  in  large  dose  sometimes  irritates  the  bladder  slightly. 
Hence,  it  is  more  applicable  to  the  declining  than  to  the  advancing  stage 
of  urethral  inflammation.  The  powder  is  often  spoken  of,  but  rarely 
given,  in  this  country.  The  fluid  extract  is  better,  in  half  teaspoon  to 
teaspoonful  doses,  hot;  the  oleoresin,  in  capsules,  perhaps  best  in  the 
dose  of  0.3  to  1  gram  (5  to  15  minims)    (1  to  3  capsules). 

Wintergreen  Oil. — This  or  its  synthetic  substitute,  methyl  salicy- 
late, is  given  in  O.Y  gram  (10  minim)  capsules,  one  or  more  at  a  dose. 

Kava-kava. — Fluid  extract  of  kava-kava  in  0.5  to  2  gram  doses  is, 
apparently,  sometimes  helpful. 

The  balsamic  remedies  have  been  found  ineffective  when  injected 
locally.  They  undergo  a  change  in  passing  through  the  kidney.  The 
excreted  urine  exercises  a  local  action  ^  upon  the  inflamed  surface  of 
the  urethra ;  consequently  the  balsams  are  useless  in  female  gonorrhea, 
unless  the  urethra  or  bladder  be  involved. 


INSTRUCTIONS   TO    PATIENTS 

Of  late  years  the  commendable  practice  has  arisen  of  distributing 
to  dispensary  patients,  suffering  from  venereal  diseases,  a  card  indicat- 

^  As  has  been  proved  when  large  fistula  in  the  floor  of  the  urethra  permitted 
the  urine  to  be  turned  off,  the  part  behind  the  opening  getting  well  first,  and  the 
anterior  urethra  being  subsequently  cured  by  injection  with  the  patient's  own  urine, 
freshly  passed  and  full  of  modified  copaiba.  I  do  not  know  that  this  has  been 
demonstrated  except  for  copaiba;  and  yet  Steinschneider  and  Schaeffer  (cited  by 
See)  found  that  the  urine  of  patients  who  had  taken  copaiba  did  not  show  bac- 
tericidal qualities. 


GENERAL  TREATMENT  OF  CHRONIC  URETHRITIS  223 

ing  the  chief  dangers  of  the  disease  and  the  precautions  they  personally 
must  take  to  encourage  speedy  cure  and  to  protect  their  fellows.  The 
following  list  has  been  approved  by  the  Associated  Clinics  of  ISFew  York 
City: 

INSTRUCTIONS  TO  THOSE  HAVING  GONORRHEA 

You  have  a  serious  contagious  disease.  It  may  continue  for  yeai-s  after 
the  discharge  ceases  and  you  seem  well.  Therefore  you  must  not  marry  or  have 
any  sexual  relations  until  a  reputable  physician  has  pronounced  you  cured. 

A  woman  with  this  disease  may  become  sterile,  or  be  an  invalid  for  life, 
or  have  to  undergo  a  very  serious  and  mutilating  operation.  A  child  born  to 
a  woman  with  this  disease  is  likely  to  become  blind. 

For  your  own  protection,  and  the  protection  of  others,  observe  the  following 
precautions : 

1.  Always  wash  the  hands  after  handling  the  parts;  the  discharge,  if  car- 
ried to  the  eyes,  will  make  you  blind. 

2.  Sleep  alone,  and  be  sure  that  no  one  uses  your  toilet  articles,  particularly 
towels  and  wash  cloths. 

3.  Never  lend  your  syringe  to  anyone,  and  as  soon  as  you  are  well,  de- 
stroy it. 

4.  Avoid  all  sexual  relations  and  excitement. 

5.  Be  sure  that  the  bowels  move  every  day.     If  constipated,  take  a  laxative. 

6.  Do  not  use  alcohol  in  any  form,  as  it  always  prolongs  the  disease. 

7.  Drink  from  six  to  eight  glasses  of  water  a  day. 

8.  Avoid  all  spicy  food  and  drink,  as  ginger  ale,  mustard,  pepper  and 
horseradish. 

9.  So  long  as  the  discharge  is  free,  walk  as  little  as  possible. 


GENERAL  TREATMENT  OF  CHRONIC  URETHRITIS 

General  Hygiene — Many  of  the  general  hygienic  rules  for  the  treat- 
ment of  acute  gonorrheal  urethritis  do  not  apply  to  the  treatment  of 
chronic  inflammations.  Thus  the  diet,  which  should  be  light  during 
the  acute  period  of  the  disease,  should  be  rather  full  and  stimulating  in 
the  chronic  stages.  Exercise,  which  is  always  harmful  in  acute  gon- 
orrhea, is  often  beneficial  to  a  chronic  case.  Exercise  should  not  only 
be  permitted,  but  should  be  encouraged.  There  is  no  reason  to  prohibit 
even  such  violent  pastimes  as  tennis  and  swimming,  to  a  patient  suffer- 
ing from  chronic  urethritis ;  hut  they  should  he  hegun  gradually,  and  the 
patient  should  feel  his  way,  taking  more  and  more  exercise  as  he  assures 
himself  that  it  does  him  no  harm. 

The  intelligent  use  of  alcohol  is  one  of  the  most  thoroughly  misun- 
derstood points  about  the  treatment  of  chronic  urethritis.  Although  we 
realize  that  many  of  the  drugs  and  methods  of  local  treatment  employed 
for  chronic  urethritis  are  used  chiefly  because  they  are  irritating,  yet 
we  forget  that  alcohol  is  one  of  the  best  known  urethral  irritants,  and 


224         SYSTEMIC  TREATMENT  OF  URETHRAL  GONORRHEA 

we  are  too  much  inclined  to  scoff  at  the  story  of  the  patient  "v.'ho,  despair- 
ing of  a  cure  after  many  months  of  treatment  for  his  local  urethritis, 
breaks  training,  enters  a  wild  debauch,  and  comes  out  of  it  cured.  Such 
a  case  is  not  the  exception  that  proves  the  rule,  but  is  only  an  illustration 
of  the  rule  that  what  we  seek  for  the  cure  of  chronic  urethritis  is  the 
proper  irritant,  and  alcohol  sometimes  fits  the  case.  Alcohol  is  almost 
universally  harmful  so  long  as  gonococci  can  lie  found  in  the  urethral 
pus  (though  there  are  rare  exceptions  even  to  this  rule)  ;  but  after  the 
gonococci  have  disappeared,  if  the  patient  is  an  habitual  drinker,  it  is 
proper  to  urge  him  to  return  gradually  to  the  use  of  alcohol,  and  such  a 
course  frequently  has  a  most  beneficial  effect,  both  upon  the  patient's 
mind  and  upon  his  catarrh.  It  is  an  exhibition  of  intelligence  on  the 
part  of  the  physician  to  cure  his  patient  by  giving  him  whisky  to  drink, 
rather  than  to  run  the  risk  of  permitting  the  patient  to  make  this 
experiment  for  himself. 

Other  hygienic  measures,  such  as  sending  a  patient  away  from  the 
city  to  the  country,  or  bidding  him  change  his  climatic  conditions  by  a 
trip  at  sea  or  to  the  mountains,  are  very  rarely  called  for.  Yet,  when 
local  measures  fail  after  a  thorough  trial,  it  is  imperative  that  the  pa- 
tient leave  his  work  and  his  home  to  take  a  vacation.  Under  such  con- 
ditions a  brief  trip  may  well  effect  cure,  or  at  least  put  the  patient 
in  such  a  condition  that  local  treatment,  which  previously  was  ineffec- 
tive, will  now  prove  curative. 

Sexual  Hygiene. — ^While  gonococci  persist  sexual  intercourse  is  as 
likely  to  reinfect  the  gonorrheic  as  it  is  to  infect  his  partner.  But  after  . 
their  disappearance  it  is  likely  to  do  good  by  relieving  the  sexual  con- 
gestion of  one  who  is  (presumably)  accustomed  to  frequent  sexual  in- 
tercourse. The  irritation  of  ungratified  sexual  desire,  the  effort  to  check 
the  sexual  habit,  is  to  many  gonorrheics  the  most  distressing  feature  of 
the  disease. 

Drugs — Most  cases  of  chronic  urethritis  may  be  treated  successfully 
without  any  internal  administration  of  drugs.  Very  exceptionally  a 
patient  is  benefited  by  the  internal  administration  of  balsamics  or  alka- 
lies. More  commonly,  a  brief,  severe  course  of  water  drinking  will  cure 
a  mild  catarrh  by  flushing  the  canal.  The  alkaline  mineral  waters  are, 
apparently,  the  best  suited  for  this  purpose.  Urotropin  is  employed  as 
an  antiseptic  preliminary  to  the  use  of  sounds  or  dilators,  and  for  the 
treatment  of  pyelonephritis  or  bacteriuria.  Alcohol  should  be  used 
intelligently,  as  stated  above.     Tonics  may  be  required. 


CHAPTER    XXIV 

LOCAL  TREATMENT  OF  ACUTE  GONORRHEA 

The  local  treatment  of  acute  gonorrhea  comprises  five  entirely  dis> 
tinct  subjects,  viz. : 

The  preventive  treatment. 

The  abortive  treatment. 

The  repressive  treatment. 

The  terminal  (expectant)  treatment. 

The  treatment  of  complications. 

THE  PREVENTIVE  TREATMENT 

The  man  who  practices  promiscuous  cohabitation  sooner  or  later 
catches  gonorrhea  in  spite  of  every  precaution.  The  condom  is  still 
"a  cuirass  against  pleasure,  a  cobweb  against  infection,"  as  Ricord  used 
to  say.  The  condom  may  tear  and  so  admit  infection ;  and  once  in  a 
great  while  one  is  consulted  by  a  victim  who  alleges  he  was  infected  in 
spite  of  its  protection.  The  infection  in  such  cases  doubtless  results 
from  preliminary  skirmishing. 

Some  measure  of  safety  is  afforded  by  urination  and  thorough  wash- 
ing with  soap  and  water  immediately  after  cohabitation.  To  this  any 
one  of  the  following  therapeutic  measures  adds  a  far  greater  assurance 
of  safety : 

Instillation  into  the  meatus  of  a  few  drops  of  20  per  cent  argyrol  or 
5  per  cent  protargol. 

Irrigation  of  the  anterior  urethra  with  permanganate  of  potassium 
(1:1,000). 

Injection  and  retention  for  five  minutes  of  20  per  cent  arg}'rol  or  1 
per  cent  protargol. 

The  safety  afforded  by  any  of  these  is  approximate  but  not  absolute. 
The  treatment  should  be  employed  within  twelve  hours  of  the  contact 
and  should  not  be  repeated.  A  traumatic  urethritis,  lasting  a  day  or 
two,  may  result. 

THE  ABORTIVE  TREATMENT 

In  the  production  of  chronic  urethritis  the  abortive  treatment  has 
taken  the  place  of  the  sound  of  our  forefathers. 

225 


226       LOCAL  TREATMENT  OF  ACUTE  GONORRHEA 

In  exceptional  cases  it  is  possible  to  abort  gonorrhea.  Indeed,  in 
some  cases  gonorrhea  almost  aborts  itself.  But  it  is  almost  impossible 
to  abort  a  first  goiiorrhea,  and  often  impossible  to  abort  subsequent  at- 
tacks. After  experimenting  with  every  method  of  aborting  gonorrhea  I 
ever  heard  of,  it  is  my  present  conviction  that  the  surest  way  to  abort 
gonorrhea  is  not  to  try  to  abort  it.  The  repressive  treatment  every  now 
and  then  results  in  a  rapid  cure.  Last  winter  I  had  the  pleasure  in  a 
single  week  of  curing  three  cases  of  acute  true  gonorrhea,  two  of  them 
within  seven  and  a  third  within  twelve  days  of  its  inception.  But  I 
treated  no  two  of  them  alike;  they  were  all  secondary  gonorrheas.  I 
made  no  attempt  to  abort  any  of  them,  and  in  the  six  months  since  that 
time  I  have  cured  but  one  case  within  four  weeks.-^ 

Bierhoff  ^  reviews  the  opinions  of  various  authorities,  and  claims  50 
per  cent  cure  for  the  following  modification  of  the  method  of  Frank  and 
Lewin  (who  report  45  per  cent  cures)  : 

A  microscopical  examination  of  the  secretion  was  first  made.  If  the  discharge 
was  slight,  and  if  the  majority  of  the  gonococci  still  were  extracellular,  then  the 
protargol  solution  was  employed  in  the  strength  of  1-6  to  1-3  per  cent.  If  the 
discharge  was  at  all  pronounced,  or  if  the  greater  part  of  the  gonococci  were 
intracellular,  then  a  1-3  to  1-2  per  cent  solution  was  used.  The  method  was 
employed,  naturally,  only  in  those  cases  in  which  the  second  urine  was  clear. 
After  urination,  the  urethra  was  anesthetized  by  an  injection  of  a  mixture  of 
4  c.c.  of  a  1  per  cent  eocain  solution  and  4  c.c.  of  a  1  per  cent  protargol  solution. 
After  this  the  anterior  urethra  was  cleansed  with  150  c.c.  of  the  protargol  solu- 
tion. Follo^ving  this,  an  irrigation  of  the  whole  urethra  was  made,  according  to 
Janet's  method,  with  150  c.c.  of  the  solution.  The  patient  then  emptied  his  blad- 
der of  the  irrigated  fluid.  This  irrigation  of  the  entire  urethra,  with  immediate 
emptying  of  the  fluid,  was  repeated  from  one  to  three  times  in  the  same  sitting, 
so  that  the  urethra  was  flushed  four  to  eight  times.  In  addition,  the  patient  was 
given  a  solution  of  jorotargol,  I/2  per  cent,  with  which  he  was  instructed  to  inject 
three  to  five  times  during  the  day,  and  to  retain  the  fluid  ten  minutes  each  time. 
During  the  succeeding  days,  if  the  gonococci  had  disappeared,  the  strength  of  the 
solution  and  the  quantity  of  fluid  injected  were  diminished,  to  be  suspended,  if 
the  result  was  positive,  on  the  fourth  or  fifth  day,  at  the  latest.  The  injections 
by  the  patient  were  also  diminished  and  suspended  in  a  similar  manner.  Then 
followed  the  usual  provocative  tests  and  control  examinations. 

Kreissl  employs  the  following  treatment  for  every  case  of  acute  ure- 
thritis of  less  than  two  days'  duration : 

After  irrigating  the  anterior  urethra  with  a  hot  boric  acid  solution  a  constrict- 
ing rubber  band  should  be  placed  around  the  penis  at  the  penoscrotal  junction, 
and  one  dram  of  a  4  per  cent  jn-otargol  solution  injected  and  retained  for  five 
minutes.    For  irrigation  with  the  boric  acid  solution  a  piston  syringe  and  a  sterile 

^  This  paragraph  was  written  in  1910.     My  conviction  remains  unsliaken  today. 
^  Med.  News,  1904,  Ixxxiv,  488. 


REPRESSIVE  TREATMENT  227 

elastic  catheter  should  be  used.  No  pressure  to  distend  the  urethra  should  be 
applied  and  the  fluid  should  commence  flowing-  through  the  catheter  before  it  en- 
ters the  urethra,  whereby  the  dissemination  of  infectious  matenal  is  avoided. 

During  the  following  eight  days  the  anterior  urethra  should  be  iiTigated  in  the 
same  manner  with  a  pint  of  a  1 :  3,000  hot  nitrate  of  silver  solution,  once  a  day. 
The  discharge,  if  there  be  any,  is  examined  microscopically  every  day.  If  no 
gonococcus  be  present  in  the  last  five  specimens,  the  treatment  may  then  be  dis- 
continued ;  otherwise,  the  systematic  treatment  for  gonorrheal  urethritis  should  be 
commenced. 

Excellent  results  are  also  attributed  to  permanganate  employed  in 
tlie  routine  way  as  described  below. 


REPRESSIVE  TREATMENT 

The  repressive  treatment  of  acute  gonorrhea  consists  in  the  employ- 
ment of  local  treatment  calculated  to  control  the  inflammation ;  but  with 
the  prime  object  of  lessening  the  symptoms,  the  complications,  and  the 
prospects  of  chronicity,  not  of  cutting  short  the  acute  attack.  The 
systemic  treatment  described  in  Chapter  XXIII  is  always  employed. 
Repressive  treatment  occasionally  and  quasi-accidentally  results  in 
abortion  of  gonorrhea.  Indeed,  I  believe  it  so  results  quite  as  often 
as  the  abortive  treatments  detailed  above,  while  it  has  the  supreme 
advantage  of  leaving  those  cases  that  are  not  aborted  soothed  rather 
than  irritated  and  in  the  best  possible  condition  to  weather  the  weeks 
to  come. 

Cases  Suitable  to  Repressive  Treatment. — The  physician  unfamiliar 
with  the  local  treatment  of  urethral  disease  can  expect  but  little  suc- 
cess with  the  repressive  treatment  of  gonorrhea.  The  expectant  treat- 
ment will  give  him  better  results. 

The  physician  moderately  familiar  with  the  subject  should  under- 
take this  treatment  with  fear  and  trembling.  He  should  apply  it  at  first 
only  to  cases  that  he  can  absolutely  control,  who  apply  for  treatment 
during  the  initial  stage  of  the  disease,  before  the  meatus  is  much  swol- 
len, the  discharge  free,  the  "second"  urine  cloudy,  or  pain  on  urination 
or  erection  present.  This  admits  most  cases  from  one  to  three  days 
old. 

The  expert  will  determine  how  far  his  personal  success  permits 
him  to  disregard  the  above  rules.  None  of  them  are  absolute  to  him, 
so  long  as  he  proceeds  gently  and  is  in  no  hurry  to  get  the  patient 
well. 

Choice  of  Repressive  Treatment. — There  are  two  entirely  distinct 
types  of  repressive  treatment,  viz. :  injection  of  organic  silver  salts  and 
irrigation  with  potassium  permanganate.  Certain  practitioners  employ 
them  simultaneously.     In  my  experience  the  silver  salts  have  proven 


228       LOCAL  TREATMENT  OF  ACUTE  GONORRHEA 

distinctly  superior  to  the  permang-anate  (which  I  used  exclusively  for 
three  years)^  and  are  most  efficacious  when  used  alone.  Permanganate 
reduces  the  inflammation  much  more  rapidly  and  clears  the  urine  far 
more  brilliantly  than  the  silver  salts,  but  gives  a  much  larger  proportion 
of  chronic  gonorrheas. 

ORGANIC   SILVER   SALTS 

A  Routine  Treatment. — I  usually  employ  0.5  per  cent  protargol. 
The  patient,  after  urinating,  injects  this  into  the  urethra  at  least  three, 
at  most  four,  times  a  day.  The  intervals  are  made  as  even  as  possible, 
and  no  interval  of  less  than  three  hours  is  permitted.  The  injection  is 
retained  five  minutes  hy  the  watch,  unless  this  excites  pain,  in  which 
event  the  duration  may  be  reduced  to  even  three  minutes  (or  the 
strength  of  the  solution  diminished). 

The  test  of  the  success  of  repressive  treatment  is  diminution  and 
disappearance  of  the  patient's  subjective  symptoms  (pain  or  discom- 
fort). The  patient  must  be  impressed  with  the  fact  that  the  success 
or  failure  of  the  treatment  is  in  his  hands,  and  that  the  sign  of  danger 
is  pain,  the  cause  of  pain  trauma.  He  must  be  gentle  in  injecting, 
gentle  in  compressing  the  meatus,  and  should  not  repeat  an  injection 
in  case  a  first  effort  fails. 

Pain  is  never  the  same  in  any  two  cases.  To  say  that  an  injection  of 
protargol  to  be  efficient  should  be  painless,  is  obviously  untrue.  But  each 
successive  injection  should  he  less  painful  than  its  predecessor,  and  the 
appearance  of  any  new  or  increased  pain  at  any  time  is  the  one  signal 
that  calls  for  immediate  consultation. 

The  patient  reports  every  day  or  every  other  day  for  the  first  week 
and  but  twice  a  week  thereafter,  until  in  the  fourth  or  fifth  week  the 
time  for  terminal  treatment  arrives. 

If  all  goes  well,  the  discharge  disappears  in  a  few  days.  The  first 
urine  becomes  almost  clear,  but  never  quite  sparkling.  The  second 
urine  remains  sparkling.     There  are  no  subjective  symptoms. 

In  from  five  to  ten  days  there  is  often  a  sudden  change  for  the  worse. 
The  discharge  increases,  the  urine  becomes  more  purulent,  there  may 
be  some  swelling  at  the  meatus,  and  pain  on  urination  and  injection. 
This  indicates  either  that  the  urethra  is  irritated  by  the  injections  or 
that  the  gonorrhea  is  escaping  control.  Injections  should,  therefore,  be 
completely  stopped.     Twenty-four  hours  later  the  patient  reports: 

1.  If  the  symptoms  have  diminished  and  no  gonococci  are  found,  no 
injections  are  given  and  the  patient  reports  daily,  each  day  carrying 
home  two  slides  to  be  smeared  with  the  morning  discharge  and  examined 
for  gonococci.  So  long  as  he  continues  to  improve  and  gonococci  do  not 
appear,  no  more  local  treatment  is  given.     If  the  urine  remains  spar- 


REPRESSIVE  TREATMENT  229 

kling  for  four  days  the  patient  is  probably  cured.     lie  is  dismissed  for 
three  days  and  the  cure  verified  in  the  usual  way  (p.  192). 

2.  If  the  symptoms  have  diminished  but  gonococci  reappear,  the 
treatment  by  injection  is  resumed. 

3.  If  the  symptoms  have  increased  or  remained  stationary,  gono- 
cocci will  almost  invariably  be  found.  The  decision  whether  or  not  to 
abandon  the  repressive  treatment  now  depends  upon  the  patient's  con- 
dition. He  should  be  treated  as  though  this  were  his  first  visit,  by 
injections  or  by  expectant  treatment. 

At  the  end  of  the  third  or  fourth  week  an  anterior  injection  of  zinc 
acetate  may  be  substituted  for  one  of  the  silver  injections  every  day  or 
every  other  day.  He  shall  be  carefully  instructed  not  to  retain  this  in 
the  urethra. 

This  brings  us  to  the  terminal  treatment  (p.  232). 

If  the  Case  Is  Seen  Late. — If  the  case  is  not  seen  until  it  is  well 
under  way,  local  treatment  will,  of  course,  be  begun  very  gingerly,  using 
0.25  per  cent  protargol  for  two  or  three  minutes  only  for  the  first  day 
or  two,  until  the  sensitiveness  of  the  urethra  abates  sufficiently  to  permit 
of  stronger  and  longer  injections.  Or  10  per  cent  argyrol  may  be  em- 
ployed. 

Treatment  of  the  Posteriok  Ueethka. — The  urine,  passed  in 
two  glasses,  is  carefully  examined  at  each  visit.  The  first  appearance 
of  haziness  (due  to  pus)  in  the  second  urine  passed  shows  involvement 
of  the  posterior  urethra.  It  must  then  be  treated  in  the  following 
manner : 

If  the  anterior  urethritis  is  not  very  well  controlled,  no  treatment 
of  the  posterior  urethra  is  required  at  the  first  appearance  of  pus  in  the 
second  urine.  Local  treatment  of  the  anterior  urethra  is  continued,  and 
if  this  promptly  brings  the  anterior  inflammation  under  control,  the  pos- 
terior urethra  is  attacked  as  described  below.  If  the  anterior  urethritis 
is  not  controlled  before  the  posterior  urethra  begins  to  show  subjective 
symptoms  (frequent  and  painful  urination),  the  physician  must  elect 
one  of  two  courses,  in  accord  with  his  prospect  of  success.  If  the  ante- 
rior urethritis  is  quite  uncontrolled  the  repressive  treatment  should  be 
abandoned;  if  there  is  still  prospect  of  controlling  it,  the  posterior 
urethra  should  be  attacked,  as  described  below.  When  in  doubt  stop  all 
local  treatment. 

If  the  anterior  urethritis  is  well  controlled  when  pus  first  shows  in 
the  second  urine,  the  posterior  urethra  should  be  promptly  attacked  with 
instillations  once  or  twice  a  day  of  20  per  cent  argyrol,  or  0.5  per  cent 
protargol,  1  c.c.  to  a  dose ;  or  by  posterior  irrigation  (very  small  catheter 
or  very  gentle  force)  with  protargol  (1:2,000),  argyrol  (1  per  cent), 
or  permanganate  (1 :  8,000),  once  a  day. 

The  selection  of  treatment  for  the  posterior  urethra  depends  upon 


230       LOCAL  TREATMENT  OF  ACUTE  GONORRHEA 

tke  experience  of  the  physician  and  the  previous  history  of  the  patient. 

If  the  posterior  urethritis  begins  to  show  symptoms  in  spite  of  this 
treatment,  the  patient  may  be  put  to  bed,  hot  sitz  bath  or  rectal  douches 
administered  twice  a  day,  and  the  treatment  continued.  If  the  symp- 
toms still  progress,  or  if  the  patient  is  unable  to  rest,  all  local  treatment 
should  be  discontinued,  and  the  case  treated  as  one  of  acute  posterior 
urethritis. 

When  Treatment  Fails. — If  pain  does  not  diminish  with  re- 
peated injections,  or  if  posterior  urethritis  becomes  uncontrollable,  all 
local  treatment  must  be  stopped.  The  occurrence  of  balanitis  or 
lymphangitis  does  not  call  for  cessation  of  local  treatment.  But  peri- 
urethritis does. 

Other  Methods  of  Treatment. — To  develop  a  system  of  repressive 
treatment  for  acute  urethral  gonorrhea  takes  a  year  or  more  of  per- 
sonal experience.  During  that  time  one's  practice  incessantly  varies, 
and,  having  developed  a  system,  the  variation  continues.  jSTew  impres- 
sions are  received  from  each  case,  and  scarcely  any  two  cases  are  treated 
in  the  same  way.  Therefore  the  practice  of  no  two  men  can  positively 
agree. 

Kreissl  says : 

Inject  Ys  per  cent  solution  of  protargol  and  retain  it  for  one  minute,  repeat- 
ing the  treatment  every  two  hours  during  the  day  and  twice  during  the 
night. 

After  three  days  a  %,  per  cent  solution  should  be  injected  eveiy  three  hours 
during  the  day  and  once  during  the  night.  At  the  end  of  the  first  week  the 
strength  may  be  increased  to  y2  per  cent,  to  be  injected  eveiy  four  hours  and 
retained  for  five  minutes,  while  the  night  injection  may  be  discontinued.  At  the 
beginning  of  the  third  Aveek  the  same  solution  may  be  injected  three  times  a  day 
and  retained  for  five  minutes  at  a  time.  At  the  beginning  of  the  fourth  week, 
when  the  secretion  will  be  found  to  contain  mostly  epithelial  cells,  no,  or  but  a 
few,  leukocytes,  and  no  gonocoeci,  an  astringent  and  mild  antiseptic  may  be  sub- 
stituted for  the  moimiug  and  noon  injection  with  protargol,  but  the  latter  should 
still  be  used  before  retiring. 

Finger  employs  0.25  per  cent  protargol  solutions,  warm,  and  always 
precedes  injection  by  a  gentle  irrigation  with  water  to  wash  away  the 
urine  that  remains  in  the  canal.  He  insists  that  the  injection  syringe 
should  contain  at  least  10  to  12  c.c.  He  retains  the  fluid  at  least  five 
minutes  and  expects  it  to  reach  the  posterior  urethra.  He  injects  three 
or  four  times  a  day.  After-  three  or  four  days  he  increases  the  strength 
of  the  protargol  to  0.5  per  cent,  then  to  2  per  cent.  Then,  in  the  second 
week,  he  begins  with  largin,  0.25  per  cent,  and  within  two  weeks  in- 
creases the  strengih  of  this  to  1  per  cent,  meanwhile  diminishing  the 
frequency  of  injection  to  once  a  day,  substituting  Ultzmann's  astringent 
injection  (p.  211)  twice  a  day. 


EEPRESSIVE  TREATMENT  231 

POTASSIUM  PERMANGANATE   IRRIGATION 

Janet's  Method. — Janet  devised  the  permanganate  irrigation  treat- 
ment for  acute  urethral  gonorrhea.  He  introduced  neither  the  drug 
nor  the  method.  But  he  combined  the  two  in  a  practical  system.  His 
instruments  are  sold  in  this  country  under  the  name  of  Valentine,  and 
his  method  is  often  incorrectly  spoken  of  as  Valentine's  method.  Janet 
irrigates  the  posterior  urethra  by  gravity,  without  a  catheter. 

He  irrigates  the  anterior  urethra  twice  a  day  for  three  or  four  days, 
then  increases  the  interval  from  twelve  to  eighteen  hours.  When  the 
cloudiness  of  the  first  urine  is  pretty  well  gone,  he  makes  the  interval 
twenty-four  hours.  When  the  discharge  is  no  longer  purulent,  he  makes 
it  forty-eight  hours. 

When  the  second  urine  becomes  cloudy,  he  irrigates  the  posterior 
urethra  according  to  the  same  method,  twice  a  day  at  first,  later  every 
day  or  every  other  day.  For  each  irrigation,  of  anterior  or  posterior 
urethra,  he  employs  500  c.c.  of  fluid,  at  a  temperature  of  110°  F. 

If  the  case  is  seen  before  the  appearance  of  marked  inflammatory 
symptoms,  he  employs  a  1 :  500  solution  of  permanganate,  immediately 
followed  by  a  like  quantity  of  boric  acid  solution.  If  this  does  not  prove 
too  irritating,  he  continues  at  this  strength  until  the  inflammation  has 
subsided  sufficiently  to  permit  intervals  of  thirty-six  to  forty-eight  hours, 
when  he  drops  to  1 :  4,000  or  1 :  6,000  permanganate  and  omits  the  boric 
acid. 

If  the  posterior  urethra  becomes  inflamed,  he  begins  irrigating  it 
with  solutions  of  1 :  4,000  down  to  1 :  10,000.  If  these  are  well  borne, 
he  increases  the  strength  to  1 :  2,000  or  1 :  1,000,  and  follows  it  with  a 
boric  acid  irrigation. 

If  the  patient  is  first  seen  after  the  appearance  of  acute  inflammatory 
symptoms,  the  irrigation  is  begun  at  1 :  10,000  to  1 :  4,000  strength,  and 
only  for  the  anterior,  even  if  the  posterior  urethra  is  inflamed.  He 
begins  treatment  of  the  posterior  urethra  only  when  the  anterior  inflam- 
mation is  under  control. 

In  the  declining  stage  he  gives  a  daily  irrigation  of  1 :  G,000  to 
1:  8,000. 

Other  Methods — Valentine  and  the  other  followers  of  the  Janet 
method  in  this  country  follow  his  method  with  certain  variations.  They 
usually  employ  much  weaker  solutions  (1:4,000  to  1:20,000)  and 
larger  quantities  (1,000  c.c.  or  more),  and  often  irrigate  the  posterior 
urethra  every  day  or  every  alternate  day  as  a  routine  measure. 

Residts. — Janet  claims  a  cure  within  three  weeks  for  most  cases  seen 
early,^  and  Valentine  says  ^ :    "I^o  other  method  can  show  90  per  cent 

*  Cf .  Monograph  in  Oberlaender,  Chr.  Gonorrhoe  d.  Manl.  Uarnrohre,  1905. 
*"The  Irrigation  Treatment  of  Gonorrhea,"  1899. 


232       LOCAL  TREATMENT  OF  ACUTE  GONORRHEA 

of  cures  in  fourteen  days."  Yet  the  method  which  was  almost  univer- 
sally tried  ten  years  ago  has  now  quite  fallen  into  disrepute.  I  can  add 
one  more  voice  to  those  assembled  in  protest  by  Horwitz.^ 

I  cannot  even  say  that  I  have  found  it  useful  in  conjunction  with  the 
silver  salts,  until  the  acute  inflammation  has  been  controlled.  But  in 
the  terminal  treatment  it  is  a  most  valuable  remedy. 


THE  TERMINAL  (EXPECTANT)  TREATMENT 

The  terminal  and  expectant  treatments  of  acute  urethral  gonorrhea 
are  not  precisely  the  same  thing.  The  expectant  treatment  consists  in 
employing  no  local  repressive  measures,  letting  the  disease  run  for  three 
to  four  weeks  until  it  begins  to  abate,  and  then  applying  local  measures. 
Terminal  treatment  includes  all  measures  applied  during  the  stage  of 
decline,  whether  the  case  has  been  through  an  expectant  or  a  repressive 
course. 

Terminal  treatment,  therefore,  begins  in  the  third  to  the  fifth  week 
of  the  disease  in  two  classes  of  cases,  viz. :  those  that  have  been  con- 
trolled, but  not  cured,  by  repressive  measures,  and  those  that  have  begun 
to  abate  spontaneously. 

Precisely  when  to  begin  terminal  treatment  in  either  event  must  de- 
pend upon  the  judgment  of  the  physician,  founded  on  his  previous 
experience. 

If  the  case  has  been  treated  expectantly,  terminal  treatment  is  begun 
according  to  the  method  used  for  repressive  treatment.  By  this  the 
symptoms  are  very  promptly  controlled,  and  within  a  week  or  so  the 
case  is  usually  ready  for  actual  terminal  measures. 

Terminal  treatment  begins  with  examination  of  the  prostate  and 
vesicles,  even  if  the  second  flow  of  urine  is  and  always  has  been  clear. 

The  patient  urinates  to  clear  the  anterior  urethra  of  pus,  but  retain- 
ing a  little  urine  in  the  bladder.  The  prostate  and  vesicles  are  then 
gently  massaged,  a  small  catheter  gently  introduced,  and  the  first  urine 
passing  through  this  caught  and  examined  for  pus.  If  this  is  found  (by 
microscope),  the  case  is  treated  as  one  of  prostatitis  or  vesiculitis  (p. 
235)  ;  if  not,  as  one  of  urethritis.  In  any  case,  this  examination  is  con- 
cluded by  a  bladder  irrigation  with  1 :  8,000  potassium  permanganate. 

Thereafter  the  patient  continues  to  use  anterior  injections  himself 
and  returns  to  the  physician  for  treatment  of  the  posterior  urethra. 

Treatment  of  the  Anterior  Urethra. — The  patient  uses  an  injec- 
tion twice,  rarely  thrice,  a  day.  If  the  discharge  contains  gonococci, 
this  injection  should  be  antiseptic  (usually  protargol,  0.5  per  cent)  ;  if 
not,  astringent  (zinc  salts).     Such  is  the  general  rule;  yet  it  is  always 

^Therap.  Gas.,  March,  1903. 


TREATMENT  OF  COMPLICATIONS  233 

well  to  experiment  with  astringents,  even  in  gonococcic  cases.  Order 
one  astringent  injection  a  day  in  addition  to  two  antiseptic  ones;  if 
this  diminishes  the  discharge  or  clears  the  urine,  the  astringent  may 
replace  the  antiseptic  still  further.  Indeed,  it  is  not  uncommon  for 
gonococcic  cases  to  do  better  under  an  exclusively  astringent  local 
treatment.  JSTongonococcic  cases,  on  the  other  hand,  may  do  well  for 
the  first  week  or  two  under  argyrol  or  protargol. 

Treatment  of  the  Posterior  Urethra — If  the  case  is  progressing 
satisfactorily  to  a  cure  under  anterior  injections,  no  treatment  of  the 
posterior  urethra  is  required.  But  if  there  is  a  halt  in  this  progress,  as 
judged  by  the  two-glass  urinary  test,  or  if  prostatic  massage  reveals 
prostatitis,  or  if  the  second  flow  of  urine  is  slightly  purulent,  treatment 
of  the  posterior  urethra  should  be  begun  by  posterior  irrigations  once  a 
day  or  once  every  alternate  day,  combined  with  the  treatment  of  pros- 
tatitis, if  this  is  present. 

The  frequency  and  the  nature  of  the  irrigation  varies  according  to 
the  idiosyncrasies  of  each  case.  Permanganate  in  weak  (1:6,000  or 
1:  8,000)  solution  is  the  most  generally  efficacious,  silver  nitrate  and 
silver  permanganate  stand  second.  If  irrigations  irritate,  instillations 
must  be  employed.  If  this  treatment  fails  to  cure  in  a  few  weeks,  the 
case  must  be  considered  chronic  and  treated  accordingly. 


TREATMENT  OF  COMPLICATIONS 

Abscess  of  the  Urethral  Glands. — Acute  relapse  or  chronic  pro- 
longation of  gonorrhea  because  of  infection  of  the  glands  or  of  the  para- 
urethral ducts  is  a  matter  for  treatment  in  the  chronic  stages  of  the 
disease ;  nothing  can  be  done  while  the  whole  urethra  remains  acutely 
inflamed. 

Periurethritis. — Stop  repressive  treatment. 

All  pus  formations  about  the  urethra,  whether  diffuse  or  circum- 
scribed, are  treated  during  the  acute  inflammatory  stage  on  general 
surgical  principles — by  rest,  protection  from  friction  and  injury,  moist 
weak  bichlorid  or  mild  carbolized  wet  dressing  under  gutta-percha  tis- 
sue. Incision  is  required  as  soon  as  the  abscess  is  as  large  as  a  pea, 
if  not  sooner.  When  the  abscess  projects  internally  and  not  externally, 
an  attempt  should  be  made  to  open  it  from  within  through  a  urethro- 
scope. 

When  permanent  fistula  results  it  should  be  treated  by  C'hctwood's 
method,  viz. :  the  injection  into  the  urethral  end  of  the  fistula  of  a  25  per 
cent  ethereal  solution  of  peroxid  of  hydrogen,  usinu'  a  fine-drawn,  rub- 
ber-capped, glass  pipette  (Fig.  4r))  with  bent  extremity. 

By  means  of  this  instrument,  aided  by  a  wire  speculum,  a  few 


234 


LOCAL  TREATMENT  OP  ACUTE  GONORRHEA 


drops  of  tlie  solution  are  thrown  into  the  fistula.  This  is  repeated  every 
three  days  until  the  fistula  closes.  This  treatment  should  be  applied 
from  within  the  urethra,  the  internal  orifice  of  the  fistula  being  en- 
larged for  that  purpose,  if  necessary,  Fistulae  that  do  not  yield  to  this 
treatment  require  a  plastic  operation. 

If  little  shotlike  bodies  remain  under  the  skin,  refusing  to  sup- 
purate actively,  these  may  be  excised,  but  fistula  may  result. 

Spongeitis  and  Cavernitis — CJiordee,  the  commonest  evidence  of 
infiammation  in  the  corpus  spongiosum,  is  a  contra-indication  to  re- 
pressive treatment.  If  the  erections  are  rendered  more  painful  by  the 
injections,  these  must  be  stopped.  Chordee  is  self -limited.  It  usually 
ceases  in  ten  days.    To  prevent  chordee  the  patient  should  eat  and  drink 


Fig.  45. — Injection  of  Urethral  Fistula.' 


little  in  the  evening,  avoid  all  sexual  associations,  sleep  under  light 
covers,  and  arise  to  urinate  in  the  middle  of  the  night.  To  palliate  it 
he  should  bend  the  erect  penis  gently  downward  and  check  the  erection 
by  immediate  urination,  or  by  first  plunging  the  penis  into  cold  water 
and  then  urinating.  Prostatic  massage  has  been  suggested  as  a  means 
to  reduce  the  sexual  tension  and  so  prevent  erections.  I  have  not 
found  it  of  any  service,  though  one  occasionally  sees  an  amorous 
patient  in  the  declining  stage  of  acute  gonorrhea  benefit  by  sexual 
intercourse. 

The  rare,  true  spongeitis  or  cavernitis  is  treated  by  rest  and  cold  or 
heat,  until  resolution  occurs  or  abscess  requires  incision. 

Balanoposthitis,  Lymphangitis — These  are  treated  in  the  usual  way 
(pp.  645  and  647). 

Paraurethral  Canals. — Inflamed  paraurethral  canals  or  pouches 
should  be  slit  up  as  soon  as  they  are  recognized,  unless  the  anterior  ure- 
thra is  acutely  inflamed  at  the  time. 


TREATMENT  OF  COMPLICATIONS  235 

Acute  Posterior  Urethritis  and  Cystitis. — Under  this  title  we  con- 
sider the  treatment  of  cases  of  posterior  urethritis  nnaccompanied  by 
palpable  change  in  the  prostate,  and  too  severe  to  be  controlled  by 
routine  treatment  of  the  posterior  urethra  (p.  171). 

In  such  cases  all  local  treatment  of  the  urethra  must  be  abandoned. 
The  patient  is  persuaded  to  rest  as  much  as  possible,  in  bed  if  the  pain 
is  very  severe.  Some  sedative,  such  as  the  liquor  potassae  and  tr. 
hyoscyami  mixture,  is  administered.  The  bromids  are,  next  to  opium, 
the  best  sedatives ;  they  may  be  added  to  the  above  mixture. 

To  alleviate  pain  I  usually  advise  the  constant  application  of  a  hot- 
water  bag  to  the  perineum,  and  a  sitz  bath  of  five  minutes  in  water  as 
hot  as  can  be  borne,  to  be  taken  twice  a  day,  or,  if  it  gives  great  relief, 
before  each  micturition.  Some  patients  prefer  to  urinate  in  the  bath. 
Hot  rectal  douches,  very  gently  administered,  not  oftener  than  twice  a 
day,  may  sometimes  be  substituted  with  advantage  for  a  sitz  bath,  but 
they  may  irritate  more  than  they  soothe.  Sedative  suppositories  of 
opium  and  other  drugs  are  singTilarly  inefficient.  Such  drugs  are  more 
effective  and  under  better  control  if  given  by  mouth. 

If  incessant  pain  continues  or  grows  worse  under  this  treatment,  and 
the  absence  of  fever  or  complete  retention,  or  of  a  prostate  palpably  in- 
flamed, shows  that  there  is  no  marked  prostatitis,  the  inflammation  may 
be  directly  attacked  (after  local  anesthetization  of  the  urethra)  by  in- 
stillation of  two  or  three  drops  of  5  to  10  per  cent  silver  nitrate  solution. 
The  instillation  should  be  administered  with  the  utmost  gentleness  in 
the  posterior  urethra. 

The  injection  may  be  repeated  in  greater  or  less  strength  every 
two  or  three  days.  Twenty  per  cent  gomenol  or  10  per  cent  argyrol 
are,  I  believe,  not  quite  so  efficacious  as  the  silver  salt. 

The  effect  of  the  injection  is  often  a  marked  diminution  in  the  pain. 
As  soon  as  this  occurs  local  treatment  is  stopped  until  the  symptoms  have 
considerably  ameliorated,  when  it  is  resumed  as  in  the  terminal  treat- 
ment (p.  232). 

If  pain  persists  in  spite  of  instillations,  the  case  is  treated  as  one 
of  acute  prostatitis. 

Acute  Prostatitis  and  Prostatic  Abscess. — In  Chapter  XVII,  we 
have  shown  the  futility  of  attempting  to  distinguish  clinically  between 
acute  prostatitis  and  prostatic  abscess. 

The  treatment  of  this  condition  is  prophylactic,  palliative,  and 
operative. 

Prophylactic  Treatment. — The  treatment  of  acute  prostatitis,  to 
be  truly  successful,  should  begin  before  there  is  any  abscess,  even 
before  there  is  any  prostatitis;  it  should  be  preventive.  To  prevent 
acute  prostatitis  the  most  important  precaution,  apart  from  gentleness 
in  all  urethral  instrumentation,  is  a  great  respect  for  the  urethra  during 


236       LOCAL  TREATMENT  OF  ACUTE  GONORRHEA 

acute  gonorrhea.  Prostatic  abscess  is  nowadays  more  often  caused 
by  intemperate  use  of  the  so-called  abortive  treatment  of  gonorrhea, 
whether  injection  or  irrigation,  than  by  anything  else.  In  only  one 
of  my  first  five  acute  gonorrheal  cases  had  the  patient  not  been  taking 
an  "abortive"  course,  while  of  the  four  whose  abscess  was  directly  due 
to  such  a  course  three  were  married  men  upon  whom  argyrol  (2)  or 
permanganate  (1)  had  been  vigorously  employed  in  the  vain  hope  of 
curing  the  disease  in  a  few  days. 

Palliative  Tkeatment. — The  palliative  treatment  is  much  the 
same  as  that  of  acute  posterior  urethritis. 

If  there  is  acute  retention,  a  small  (15  F.)  soft-rubber  catheter 
should  be  introduced  three  or  four  times  a  day,  and  followed  by  a  mild 
antiseptic  irrigation  until  retention  is  relieved,  though  if  spontaneous 
urination  is  not  established  within  a  day  or  so,  or  if  catheterism  is  diffi- 
cult or  painful  (because  of  stricture  or  inflammation),  one  should 
operate  at  once. 

To  sum  up,  the  palliative  treatment  consists  of : 

1.  Stopping  all  urethral  treatment. 

2.  The  administration  by  mouth  of  some  soothing  urinary  anti- 
septic with  whatever  sedative  and  laxative  may  be  necessary. 

3.  Insistence  upon  the  general  rules  of  antigonorrheic  treatment, 
especially  as  to  physical  rest ;  rest  in  bed,  if  there  is  fever. 

4.  Hot  sitz  baths  or  hot  rectal  douches,  with  the  hot-water  bag  as 
local  sedative. 

5.  Catheterism  and  bladder  wash  if  there  is  complete  retention. 
As  a  result  of  this  treatment  we  look  for  prompt  relief  of  two  symp- 
toms, viz.,  fever  and  retention. 

If  the  patient's  temperature  does  not  within  a  few  days  fall  to  and 
remain  below  100°  P.,  and  if  acute  complete  retention  is  not  almost 
immediately  relieved,  the  abscess  should  be  promptly  operated  upon. 

Such  a  rule  may  seem  unnecessarily  severe,  even  brutally  surgical, 
for  it  takes  no  account  of  the  precise  pathological  conditions  within  the 
prostate.  Yet  it  is  fully  as  justifiable,  fully  as  necessary,  as  the  rule  to 
operate  early  in  acute  appendicitis.  In  each  disease  unexpected  cure 
without  operation  may  follow  a  long  and  distressing  illness.  But  such 
a  cure  is  not  to  be  compared  with  the  immediate  relief  following  upon 
operation,  while  the  entire  safety  of  such  an  operation,  if  promptly 
and  properly  performed,  contrasts  strikingly  with  the  miserable  and 
even  fatal  results  of  palliative  treatment  unwisely  prolonged.^ 

Operative  Treatment. — See  p.  730. 

Seminal  Vesiculitis  and  Deferentitis — The  seminal  vesicle  very 
rarely  requires  treatment  during  acute  urethral  gonorrhea.  Acute  in- 
flammation in  it  is  rare  and  is  habitually  but  a  minor  accompaniment 

^Keyes,  N.  Y.  Polyclinic  Med.  Jour.,  1»08,  Nos.  9  and  10. 


TREATMENT  OF  COMPLICATIONS  237 

to  a  more  important  acute  prostatitis.  The  treatment  is  the  palliative 
treatment  of  acute  prostatitis. 

When  active  suppuration  occurs  in  or  about  the  vesicle,  this  is  usu- 
ally not  discovered  until  adhesion  with  the  bowel  has  taken  place.  In 
this  event  the  abscess  should  be  incised  from  the  rectum.  But  if  sup- 
puration tends  to  spread  off  into  the  ischiorectal  fossa  or  threatens  the 
peritoneum,  vesiculotomy  should  be  performed. 

Epididymitis. — See  p.  566. 

Pyelonephritis See  p.  350. 


CHAPTEK   XXV. 
LOCAL  TREATMENT  OF  CHRONIC  URETHRITIS 

The  treatment  of  chronic  urethritis  is  entirely  empirical,  as  is  the 
treatment  of  chronic  catarrh  of  any  mucons  membrane.  So  mnch  de- 
pends upon  the  physical  character  of  the  patient  himself,  and  so  mnch 
npon  the  precise  way  in  which  local  treatment  is  conducted,  that  it  is 
impossible  for  any  two  men  to  treat  the  condition  by  precisely  the  same 
method.  It  is  to  be  borne  in  mind  that  the  milder  forms  of  chronic  ure- 
thritis tend  to  get  well  spontaneously  under  proper  general  and  sexual 
hygiene.  The  cases  that  resist  local  treatment  most  effectively  are  not 
those  that  most  seriously  threaten  the  patient's  health,  but  rather  the 
minor  catarrhs ;  while  the  more  severe  inflammations,  such  as  stricture 
of  the  anterior  urethra  and  marked  suppuration  in  the  prostate  and 
seminal  vesicles,  usually  yield  to  intelligent  local  treatment.  But  it  is 
impossible  to  decide  beforehand  precisely  what  treatment  will  suit  a 
given  case.  The  most  anemic  and  neurotic  patient  may  be  cured  by  a 
few  irrigations,  while  the  most  robust  ma}"  show  a  slight  catarrh  that 
resists  every  local  and  general  measure.  It  is  of  the  first  importance, 
therefore,  that  the  patient's  general  and  sexual  hygiene  be  closely  in- 
vestigated, and  every  effort  made  from  the  outset  to  put  him  in  the 
best  possible  circumstances  for  overcoming  his  local  inflammation 
(p.  223). 

In  the  second  place,  it  is  important  that  whatever  local  treatment  is 
undertaken  should  be  given  for  the  definite  purpose  of  curing  a  knovsm 
lesion.  Yet  this  local  treatment  should  be  carried  out  in  a  purely 
tentative  way,  for  it  is  impossible  to  decide  beforehand  which  of  the 
various  lesions  along  the  urethra  is  the  important  one,  and  it  is  equally 
impossible  to  be  sure  whether  any  form  of  local  treatment  will  do  good 
rather  than  harm  until  it  has  been  tried.  It  is,  therefore,  necessary  to 
conduct  treatment  with  a  close  eye  to  results,  and,  unless  some  definite 
change  for  the  better  is  promptly  perceived,  the  treatment  must  be 
changed.  In  making  these  changes  it  is  wise,  every  little  while,  to 
take  a  breathing  space — to  stop  all  local  treatment  and  give  the  urethra 
a  few  weeks'  rest,  controlling  the  discharge,  if  need  be,  by  an  anterior 
astringent  injection. 

Bearing  these  general  considerations  in  mind,  we  may  proceed  tc 
detail  the  methods  of  treatment  employed,  beginning  with  those  most 

238 


INJECTIONS,  IRRIGATIONS  AND  INSTILLATIONS  239 

commonly  used  and  ending  with  tlie  ones  tliat  are  only  required  for  ex- 
ceptional cases,  aad  not  forgetting  hygiene  (p.  223). 


INJECTIONS,  IRRIGATIONS  AND  INSTILLATIONS 

Unless  there  is  some  indication  to  the  contrary,  the  first  local  treat- 
ment to  be  employed  upon  any  patient  with  chronic  urethritis  is  urethral 
injection  or  iirigation.  It  is,  perhaps,  a  matter  of  taste  whether  to  be- 
gin, as  a  routine  measure,  by  bidding  the  patient  to  use  injections  for 
the  anterior  urethra  or  to  return  to  his  physician  for  irrigations  of  the 
posterior  urethra.  ISTo  fixed  rule  can  be  given.  If  the  discharge  is 
profuse,  it  is  usually,  but  not  necessarily,  wise  to  begin  with  injections. 
If  it  is  slight,  irrigations  may  usually  be  depended  upon  alone.  The 
patient's  mental  attitude,  the  frequency  with  which  he  is  able  to  return 
for  treatment,  and  the  results  of  experimental  treatment  in  each  direc- 
tion, must  be  the  guide  in  a  given  case. 

Injection. — The  astringent  injections  are  the  most  generally  useful. 
My  preference  is  for  the  zinc  acetate  mixture  (p.  213)  employed 
twice  a  day  and  retained  in  the  urethra  only  long  enough  to  fill  the 
canal.  'No  effort  should  be  made  to  prevent  its  reaching  the  deeper 
portions  of  the  urethra,  nor  should  it  be  forced  into  the  posterior  canal. 

If  the  discharge  is  profuse  and  contains  gonococci,  the  organic  silver 
salts,  notably  protargol,  may  prove  more  effective  than  the  astringents ; 
but  the  more  chronic  the  case,  the  less  likely  are  the  silver  salts  to  do 
good.  Whatever  injection  is  employed  may  do  good  at  first  and  irritate 
later.  Its  use  should,  therefore,  be  intermitted  every  few  weeks.  The 
chief  value  of  this  injection  is  that  it  keeps  the  patient  clean,  by  con- 
trolling the ,  discharge  until  time  and  treatment  shall  cure  the  ure- 
thritis. 

Irrigation — Having  completed  the  diagnosis  in  the  manner  de- 
scribed on  p.  194,  it  is  my  custom  to  begin  treatment  by  irrigating  the 
bladder  with  permanganate  of  potassium  (1:4,000  every  day  or 
every  other  day).  Even  if  the  prostate  is  mildly  involved,  it  is  often 
better  to  neglect  this  for  the  time,  until  the  surface  inflammation  is  a 
trifle  calmed  by  the  irrigations. 

If  three  or  four  irrigations  do  no  good,  a  change  may  be  made  by 
increasing  the  strength  of  the  solution,  or  by  adding  to  each  500  c.c.  ten 
drops  of  a  10  per  cent  silver  nitrate  solution. 

If  the  prostate  and  vesicles  are  markedly  involved,  massage  upon 
them  is  begun  and  continued  according  to  the  rules  given  below. 

At  this  time,"  also,  infiltrations  or  strictures  of  large  calibcM-  in  the 
anterior  urethra  are  to  be  sought  for  (p.  19 G)  and  dilated. 

Instillations. — If  the  posterior  urethritis  is  severe,  instillations  are 


240  LOCAL  TREATMENT  OF  CHRONIC  URETHRITIS 

to  be  employed  at  first,  instead  of  irrigations,  wliile  if  it  is  exceptionally 
mild,  but  the  patient  has  many  subjective,  painful,  or  neurotic  symp- 
toms, instillations  of  nitrate  of  silver  are  usually  preferable.  As  the 
urethritis  approaches  a  cure  one  should  always  employ  instillations. 


DILATATION  AND  MASSAGE 

One  of  the  most  difficult  problems  in  the  treatment  of  chronic  ure- 
thritis is  the  intelligent  use  of  dilatation  and  massage.  Theoretically, 
every  sclerotic  anterior  urethra  should  be  dilated  until  the  sclerosis  dis- 
appears and  the  surface  of  the  mucous  membrane  appears  healed  when 
observed  througli  the  urethroscope.  Theoretically,  every  inflamed  pros- 
tate and  seminal  vesicle  should  be  massaged  until  it  no  longer  yields 
pus.  Practically,  the  most  successful  practitioners  honor  these  rules 
more  in  the  breach  than  in  the  observance.  Many  an  anterior  urethra 
becomes  and  remains  apparently  well,  though  it  bears  untreated  scars. 
Many  a  prostate  continues  to  excrete  pus,  in  spite  of  all  that  can  be 
done  by  the  most  vigorous  and  long-continued  massage.  Indeed,  if  one 
follows  these  cases  as  I  have  done,^  treating  them  up  to  the  point  of 
clinical  cure,  then  observing  them,  and  massaging  the  prostate  as  part 
of  the  observation  every  few  nionths  for  a  year  or  more  thereafter,  one 
is  surprised  to  note  that  a  prostate,  the  treatment  of  which  was  stopped 
with  some  misgivings,  will  often  show  less  pus  in  its  secretion  several 
months  later  than  it  did  while  treatment  was  being  pushed.  If  relapse 
is  noted  after  the  interval,  especially  if  that  relapse  be  only  in  the 
shape  of  an  increased  amount  of  pus  in  the  secretion,  without  any 
subjective  symptoms  or  urinary  signs,  a  few  rubs  usually  set  things 
right  again. 

On  the  other  hand,  if  dilatation  is  persisted  in  until  the  urethroscope 
shows  a  perfectly  satisfactory  condition  of  the  mucous  membrane,  or  if 
massage  of  the  prostate  and  vesicles  is  persisted  in,  long  after  the  dis- 
appearance of  symptoms  and  urinary  signs,  in  the  hope  of  expressing  a 
last  pus  corpuscle  from  these  organs,  the  case  is  likely  to  be  sadly  over- 
treated.  This  is  especially  true  in  the  matter  of  massage.  It  is  almost 
impossible  to  remove  the  last  trace  of  pus  from  the  prostate,  the  seat 
of  severe  or  prolonged  chronic  inflammation.  After  a  thorough  course 
of  rubbing  with  this  end  in  view,  the  prostatitis  is  quite  as  likely  to 
relapse  as. though  the  patient  had  been  more  moderately  treated,  with 
a  view  to  controlling  and  not  eradicating  the  prostatic  suppuration. 
Relapse  after  such  a  course  of  treatment  is  the  making  of  a  sexual 
neurasthenic. 

The  fear,  so  commonly  expressed  both  by  the  profession  and  by  the 

^Jour.  Am.  Med.  Assn.,  1904,  xliii,  187. 


DILATATION  AND  MASSAGE  241 

laity,  that  chronic  prostatitis  leads  to  prostatism,  is  without  clinical 
foundation.  In  the  report  referred  to  I  have  shown  that,  among  men 
of  a  given  age,  prostatic  retention  is  less  common  if  they  have  suffered 
from  severe  and  prolonged  prostatitis  in  their  youth  than  it  is  among 
their  more  fortunate  brethren  who  either  deny  gonorrhea  absolutely,  or, 
at  most,  have  not  had  severe  prostatic  inflammatory  complications  from 
this  disease.  Were  prostatitis  so  much  to  be  dreaded  as  a  cause  of 
prostatism  as  some  of  our  brethren  maintain,  given  the  fact  that  pros- 
tatitis is  so  common  a  complication  of  gonorrhea  as  these  same  brethren 
gladly  admit,  one  might  expect  to  see  in  the  generation  which  has  now 
passed  its  fiftieth  year,  and  which  went  through  its  gonococcic  period 
at  a  time  when  no  finger  invaded  the  prostatic  penetralia,  an  over, 
whelming  proportion  of  prostatics — many  times  more  than  the  clinirg 
actually  shows. 

Theory  of  Dilatation  and  Massage.— The  important  pathologic 
changes  of  chronic  urethritis  occur  chiefly  below  the  surface,  in  the 
glands  of  the  anterior  and  the  posterior  urethra,  and  in  sclerosis  of  the 
mucous  membrane  about  these  inflamed  glands.  The  reason  for  employ- 
ing dilatation  of  the  anterior  urethra  and  massage  of  the  posterior 
urethra  in  the  treatment  of  chronic  urethritis  is,  therefore,  twofold. 
First,  in  order  to  express  the  accumulated  secretions  from  the  glands 
and  thereby  to  permit  them  mechanically  to  return  to  a  more  normal 
condition;  and  secondly,  by  making  pressure  upon  the  inflammatory 
tissue  about  these  glands,  and  especially  about  their  orifices,  to  encourage 
resorption  of  this  exudate  and  to  discourage  its  change  into  a  permanent 
scar.^ 

One  might  suppose,  a  priori,  that  every  chronic  urethritis,  therefore, 
required  either  dilatation  or  massage,  and  more  probably  both,  but  such 
is  far  from  being  the  case.  Some  inflamed  urethras  heal  not  only  as 
well,  but  even  better,  without  these  measures.  Massage  of  the  prostate 
and  vesicles  may  prove  irritating  rather  than  beneficial,  and  the  danger 
from  irritation  by  the  use  of  sounds  and  dilators  in  the  urethra  is  well 
known.  Moreover,  the  moderately  inflamed  anterior  or  posterior  ure- 
thra gets  well  without  mechanical  pressure  in  many  instances.  Hence, 
it  is  well  to  reserve  massage,  and  even  more  carefully  to  reserve  dila- 
tation, for  those  cases  that  really  need  it — that  are  not  curable  with- 
out it.  One  can  scarcely  be  too  enthusiastic  about  the  advantages  of 
these  methods  of  treatment  if  one  always  bears  in  mind  their  dangers. 

Technic  of  Dilatation. — If  examination  with  the  bulbous  bougie 
reveals  an  induration  in  the  anterior  urethra,  which  is  not  promptly 
ameliorated  or  cured  by  irrigations,  it  should  be  dilated.     If  the  pa- 

^Tlie  use  of  electricity  (Newman),  hot  solutions  or  hot  sounds  (Porosz,  Am. 
Jour,  of  Urol.,  Jan.,  1911),  to  excite  liyperemia  and  replace  dilatation,  has  not  met 
with  any  general  success. 


242  LOCAL  TREATMENT  OF  CHRONIC  URETHRITIS 

tient's  meatus  is  sufficiently  large,  the  dilatation  should  be  begun  with 
sounds,  and  these  should  be  carried  to  the  limit  of  the  meatus.  The 
urethra  should  be  dilated  not  more  than  three  numbers  at  a  given  occa- 
sion, and  the  usual  precautions  as  to  hexamethylenamin  and  local  anti- 
sepsis should  be  employed. 

When  the  first  sound  is  passed,  the  urethra  should  be  palpated  upon 
it  to  discover  any  perceptible  infiltrations  or  minute  glandular  indura- 
tions, and  if  these  are  found  they  should  be  gently  massaged  each  time 
the  sound  is  introduced  thereafter  until  they  disappear,  or  until  it 
becomes  evident  that  they  are  permanent  scars. 

Sounding  should  be  repeated  twice  a  week,  and  when  the  limit  of 
the  meatus  is  reached,  dilatation  with  the  Kollmann  dilator  should  be 
begun.  In  using  the  dilator  it  is  often  possible  to  advance  much  more 
rapidly  than  with  the  sound.  The  instrument  is  screwed  up  gently,  one 
waits  a  moment,  and  then  gently  turns  the  wheel  a  trifle  more.  By  thus 
turning  intermittently,  one  gains  two  or  three  numbers  with  little  pain 
to  the  patient  and  without  exciting  much  bleeding, 

I  see  no  advantage  in  leaving  sounds  or  dilators  in  the  urethra  for 
more  than  a  few  moments  after  the  desired  dilatation  has  been  achieved. 

It  is  a  general  rule  that  bleeding  is  a  sign  of  too  severe  dilatation. 
Yet,  if  the  surface  of  the  urethra  is  much  inflamed,  the  very  introduc- 
tion of  the  instrument  may  cause  bleeding. 

CoNTRA-iNDicATiows  TO  DiLATATioN. — While  gouococci  pcrsist  in 
the  urethra,  dilatation  is  dangerous:  It  may  do  good ;  it  is  more  likely  to 
do  harm.  While  the  urine  contains  free  pus,  even  though  that  pus  show 
no  gonococci,  dilatation  is  still  somewhat  dangerous,  and  should  be  un- 
dertaken only  after  every  effort  to  clear  the  urine  of  free  pus  has  failed ; 
but  when  only  a  very  light,  purulent  cloud  remains,  and  the  urine  shows 
many  shreds,  dilatation  is  likely  to  be  most  serviceable  and  almost  free 
from  danger.  Yet  it  is  always  possible  that  the  dilatation  may  excite 
acute  prostatitis  or  epididymitis.  These  may  be  avoided,  to  be  sure,  bj 
restricting  the  dilatation  to  the  anterior  urethra.  Yet  the  dilatation, 
to  be  efficient,  must  include  the  posterior  urethra,  since  the  bulb  and  the 
membranous  portion  are  likely  to  be  the  regions  most  in  need  of 
stretching. 

The  sensitiveness  to  dilatation  may  be  overcome  by  the  use  of  local 
anesthesia. 

Technic  of  Massage. — One  often  speaks  of  massaging  the  prostate ; 
but  it  is  prudent,  in  view  of  the  fact  that  the  vesicles  may  be  inflamed 
even  when  they  feel  normal,  always  to  massage  the  vesicles  first  and 
then  the  prostate,  no  matter  which  organ  feels  the  most  diseased,  though 
paying  most  attention  to  obviously  diseased  regions. 

The  question  whether  these  organs  should  be  massaged  severely  or 
gently  cannot  be  decided  academically.    A  physician  who  rubs  so  hard 


DILATATION  AND  MASSAGE  243 

as  to  make  many  of  his  patients  faint  loses  many  a  case  before  it  can 
be  cured ;  and,  on  the  other  hand,  the  physician  who  massages  too  gently 
fails  to  cure  certain  cases  that  require  severe  rubbing.  The  intelligent 
practitioner  will  rub  gently  at  first  and  increase  the  severity  of  the 
manipulation  up  to  the  point  of  the  patient's  endurance,  and  with  an 
eye  to  the  results  obtained.  Severe  massage  may  do  physical  harm 
by  exciting  acute  prostatitis,  vesiculitis,  and  epididymitis.  Mild  mas- 
sage very  rarely  does  this.  No  two  physicians  massage  with  pre- 
cisely the  same  method  or  with  precisely  the  same  severity,  as  patients 
are  quick  to  note. 

A  simple  method  is  to  begin  upon  one  vesicle,  and,  reaching  up  as 
far  toward  its  fundus  as  possible,  to  press  upon  it  and  then  withdraw 
the  finger  in  a  zigzag  way  until  one  reaches  the  prostate.  This  maneu- 
ver is  repeated  half  a  dozen  times  and  then  the  same  treatment  given 
to  the  opposite  vesicle.  If  the  vesicles  are  impalpable,  this  is  enough. 
If  distended  or  indurated,  the  maneuver  should  be  repeated  often 
enough  to  make  a  distinct  reduction  in  their  size,  if  the  patient  can  bear 
so  much  manipulation. 

The  finger  is  then  brought  down  to  the  prostate.  Hard,  angular  in- 
durations in  and  about  this  organ  had  best  be  avoided,  and  pressure 
made  chiefly  upon  the  more  yielding  portions  of  the  gland.  Beginning 
with  one  lobe,  pressure  is  made  upon  it  either  with  a  to-and-fro  lateral 
sweep  of  the  finger  or  with  a  circular  motion.  This  manipulation,  if 
gentle,  may  be  continued  for  one  minute ;  if  severe,  half  a  dozen  strokes 
may  sufiice.  The  same  treatment  is  given  the  opposite  lobe  of  the  gland, 
and  the  manipulation  concluded  by  a  half  dozen  strokes  over  the  pros- 
tatic sinus  for  the  purpose  of  emptying  the  main  ducts  into  the  urethra. 
The  general  tendency  of  all  such  massage  should  be  to  express  the 
secretions  in  the  direction  of  the  apex  of  the  prostate. 

Meanwhile,  watch  is  kept  for  the  expulsion  of  secretion  from  the 
meatus.     This  is  caught  upon  a  slide  for  examination. 

Massage  should  usually  be  repeated  not  oftener  than  two  or  three 
times  a  week.  If  severe,  longer  intervals  are  better.  In  exceptional 
cases,  when  the  return  from  massage  is  very  great,  gentle  rubbing  may 
be  employed  once  a  day.  Massage  should  be  continued  until  the  sub- 
jective symptoms  are  relieved,  and  the  return  from  the  rubbing  very 
slight  and  not  densely  purulent.  If  the  return  to  nonnal  is  rapid,  one 
may  continue  to  rub  until  all  pus  disappears.  The  success  of  treatment 
must  almost  always  be  verified  by  three  or  four  observations  at  intervals 
of  one  to  three  months.  If  pus  has  reaccumulated  during  these  inter- 
vals, a  few  rubs  will  get  rid  of  it. 

CoNTRA-iNDiCATiON  TO  Massage. — Massagc  is  dangerous  only  in 
the  presence  of  acute  inflammation  of  the  urethra,  the  prostate,  the 
vesicle,  or  the  epididymis;  but  massage  is  hannful  in  case  it  increases 


S44  LOCAL  TREATMENT  OF  CHRONIC  URETHRITIS 

the  patient's  subjective  symptoms  instead  of  relieving  them.  It  is  also 
harmful  in  case  it  so  hypnotizes  the  patient  that  he  thinks  he  must  come 
for  the  rest  of  his  natural  days  to  be  rubbed  for  the  relief  of  imaginary 
discomforts.  Such  patients  should  be  discouraged  from  massage  by  all 
possible  means.     Their  proper  cure  is  sexual  relief  by  matrimony. 


THE  RECTAL  DOUCHE 

The  rectal  douche  is  an  accessory  or  substitute  to  massage  of  the 
prostate  and  vesicles.  The  usual  case,  that  can  perfectly  well  submit  to 
massage,  need  not  bother  with  douches.  But  if  the  patient  cannot  reach 
his  physician  often  enough  for  massage,  if  the  inflammation  is  too  acute 
for  massage,  or  if  massage  proves  irritating,  the  rectal  douche  should 
be  employed.  The  object  of  the  rectal  douche  is  to  apply  heat  or  cold 
to  the  prostate  or  vesicles.  The  mechanism  and  technic  have  already 
been  described  (p.  209).  The  injection  should  be  repeated  every  day, 
with  an  interval  of  a  few  days,  every  two  or  three  weeks,  to  make  sure 
that  the  bowel  is  not  being  irritated.  Some  patients  note  an  immediate 
sense  of  relief  from  the  use  of  the  rectal  douche,  but  the  majority  do 
not,  and  it  is  often  difficult  to  persuade  a  patient  to  go  on,  week  after 
week,  using  a  treatment  which  is  a  great  nuisance  and  which  does  not 
appear  to  him  beneficial.  Yet  the  rectal  douche  is  one  of  the  few  forms 
of  treatment  that  may  be  continued  for  months  at  a  time,  with  only 
such  intervals  as  are  necessary  to  insure  the  comfort  of  the  bowel. 


OPERATIVE  TREATMENT 

In  the  absence  of  complications  specifically  requiring  operations, 
such  as  intractable  stricture,  or  abscess,  it  is,  generally  speaking,  un- 
wise to  operate  upon  cases  of  chronic  urethritis.  Intractable  cases  of 
prostatic  neuralgia  have  been  cured  by  scraping  the  posterior  urethra, 
but  such  a  treatment  would  seem  more  likely  to  do  harm  than  good  in 
most  cases.  Young  ^  advises  prostatectomy  for  the  treatment  of  chronic 
prostatitis;  but  his  best  results  are  obtained  in  cases  of  retention,  and 
it  is  obvious  that  retention  from  prostatic  bar  or  contracture  in  a  young 
man  requires  the  same  operative  treatment  for  its  cure  as  does  pros- 
tatic retention  in  the  aged.    Dilatation  does  these  cases  no  good. 

Operations  for  the  Relief  of  Vesiculitis. — The  operative  relief  of  in- 
fections of  the  seminal  vesicles  has  been  attempted  in  two  ways :  by 
drainage  through  the  vas  deferens,  and  by  direct  operative  attack  upon 
the  vesicle  itself. 

^  Johns  Hopkins  Hospital  Eeport,  vol.  xiii. 


OPERATIVE  TREATMENT  245 

Belfield^s  Operation. — Belfield  picks  up  the  vas  in  the  scrotum, 
incises  it  after  local  infiltration  of  the  skin  with  coca  in,  injects  the  prox- 
imal end  of  the  duct  with  10  per  cent  argyrol  or  4  per  cent  collargol, 
and  fixes  the  duct  in  the  wound  so  that  any  reflux  of  the  fluid  injected 
will  issue  from  the  wound  itself  and  not  flow  into  the  subcutaneous 
tissue,  there  to  cause  an  irritative  phlegmon.  He  hopes  thus  to  obtain 
both  antisepsis  and  drainage  of  the  vesicle.  Edema  around  the  little 
wound  interferes  with  subsequent  injections.  Excellent  results  have 
been  reported  from  this  operation,  and  it  is  believed  that  if  the  vas  is 
not  completely  divided  or  if  it  is  brought  together  again  by  a  single 
catgut  suture  so  that  the  two  ends  are  opposed  to  each  other,  occlusion 
of  the  vas  does  not  occur.  (Contrary  to  what  one  would  expect,  experi- 
ments seem  to  bear  out  this  statement.) 

Thomas  has  suggested  that  the  injection  be  made  through  a  needle 
puncture  of  the  exposed  vas.  This  readily  finds  the  lumen  and  sup- 
plies antisepsis  without  drainage.  Whatever  form  of  operation  is  em- 
ployed, care  must  be  taken  not  to  infiltrate  the  tissues  about  the  vas. 

The  operation  is  simple  enough.  In  my  hands  it  has  been  quite 
without  effect  excepting  in  a  few  cases  of  recurrent  epididymitis.  I  am 
inclined  to  suspect  that  the  benefit  in  these  cases  has  been  due  to  occlu- 
sion of  the  vas  at  the  point  of  operation. 

Vesiculotomy  and  Vesiculectomy. — The  direct  attack  upon  the 
vesicle  is  much  more  successful,  both  for  the  relief  of  rheumatism  and 
of  pain.  Most  authors  employ  vesiculotomy,  though  Cabot,  believing 
that  no  simple  incision  can  really  drain  such  a  complicated  tube  as  the 
vesicle,  has  employed  vesiculectomy.  The  operation  unquestionably 
relieves  the  rheumatic  pain  of  a  large  class  of  patients,  but  it  fails  in  a 
totally  indeterminate  number  of  cases.  When  vesiculotomy  fails,  ves- 
iculectomy combined  with  prostatectomy  may  succeed,  though  even  this 
does  not  g-uarantee  a  cure.  The  operation  has  been  applied  to  a  very 
loosely  classified  type  of  painful  cases;  its  value  in  the  treatment  of 
these  is  open  to  doubt.  I  have  employed  it  several  times  with  no  success. 
In  the  acute  stages  of  gonorrheal  rheumatism  it  is  likely  to  prove  bril- 
liantly successful,  but  many  of  these  cases  are  readily  relieved  by  other 
means.  Therefore  the  operation  is  usually  reserved  for  intractable 
cases,  the  majority  of  whom  it  cures.  It  does  not,  however,  protect  the 
patient  against  a  relapse,  if  he  becomes  re-infected  with  gonorrhea. 

Impotence  follows  vesiculotomy  in  a  very  small  percentage  of  cases. 
It  is  a  common  result  of  vesiculectomy.  I  have  operated  upon  but 
very  few  cases  and  with  no  resulting  impotence. 


246  LOCAL  TREATMENT  OF  CHRONIC  URETHRITIS 


URETHEOSCOPIC   TREATMENT    (See  p.  203) 

The  anterior  urethra  should  be  examined  with  the  urethroscope, 
either  at  the  time  that  dilatation  seems  indicated  or  at  the  time  that 
it  fails  to  do  good.  If  urethroscopic  observations  are  made  throughout 
the  course  of  treatment,  the  disappearance  of  infiltrations  and  the 
return  of  the  mucous  membrane  to  normal,  or  the  final  scarring  of  the 
urethra  may  be  noted. 

Urethroscopic  treatment  may  be  considered  under  two  heads,  viz. : 

1.  Topical  applications  to  various  inflammatory  lesions  of  the 
anterior  and  posterior  urethra,  and 

2.  Treatment  of  the  urethral  neuroses  usually  dependent  upon  in- 
flammation of  the  verumontanum  and  utricle. 

Topical  Applications. — If  anterior  urethritis  resists  treatment  by 
the  ordinary  injection  and  dilatation,  the  urethroscope  usually  reveals 
localized  areas  of  infiltration,  in  the  midst  of  which  are  seen  inflamed 
glands  which  may  or  may  not  exude  pus.  Applications  to  these  spots 
may  be  made  through  the  urethroscope  by  means  of  a  cotton  tampon  on 
a  wooden  applicator.  ISTitrate  of  silver  in  5  per  cent  to  20  per  cent 
strength  is  the  drug  most  commonly  used.  Sulphate  of  copper  may  be 
used  in  the  same  strength,  or  equal  parts  of  iodin  and  carbolic  acid 
may  be  employed.  The  applications  are  made  precisely  to  the  inflamed 
spot,  after  it  has  been  touched  with  a  dry  piece  of  cotton,  in  order  to 
rid  it  of  secretions.  ISTo  excess  of  the  solution  should  be  permitted  to 
run  over  healthy  parts  of  the  mucous  membrane.  The  treatment  may 
be  repeated  not  oftener  than  twice  nor  less  often  than  once  a  week. 
I  cannot  say  that  it  has  succeeded  brilliantly  in  my  hands.  Swinburne 
praises  the  fulgiiration  treatment  of  such  lesions. 

For  suppuration  in  a  paraurethral  canal  the  best  treatment  is  in- 
jection of  10  per  cent  nitrate  of  silver.  If  this  fails  to  cure  after  two 
or  three  injections,  the  canal  should  be  split  from  end  to  end  by  means 
of  a  urethroscopic  knife  (Janet's  trajectotome  is  the  most  convenient 
instrument),  or  destroyed  by  fulgiiration. 

Granulations  and  papillomata  are  also  readily  destroyed  by  ful- 
guration. 

TREATMENT  OF  URETHRAL  NEUROSES 

The  neuroses  due  to  chronic  prostatitis  and  seminal  vesiculitis  may 
or  may  not  be  postgonorrheal,  as  has  already  been  suggested.  Yet  they 
are  often  attributed  to  gonorrhea  by  the  patient,  and  are,  therefore,  con- 
sidered under  this  aspect. 

They  may  be  divided  into  three  groups: 


TEEATMENT  OF  URETHRAL  NEUROSES  247 

Sexual  neuroses. 
Painful  neuroses. 
Sexual  neurasthenia. 

To  these  may  be  added,  for  the  sake  of  convenience : 
Prostatorrhea. 
Spermatorrhea. 

In  order  properly  to  treat  these  various  conditions,  an  accurate  diag- 
nosis is  necessary  as  to  the  presence  of  complications. 

If  gonococci  are  present,  one  must  first  get  rid  of  these  by  appropri- 
ate measures.  If  the  prostate  and  vesicles  are  markedly  inflamed,  these 
must  be  massaged  until  the  amount  of  pus  expressed  is  reduced  to  a 
minimum.  If  there  is  stricture,  this  must  be  dilated ;  if  there  is  resid- 
ual urine  without  any  other  pathological  cause,  this  may  be  set  down  to 
the  sclerosis  of  the  prostatic  glands  about  the  bladder  neck,  and  is  best 
treated  by  incision  with  the  galvanocautery  (p.  746).  If  the  urethra  is 
hyperesthetic,  this  oversensitiveness  must  be  dulled  by  the  gentle  passage 
of  sounds  as  large  as  the  patient  can  bear. 

The  jjroper  treatment  for  ijain  is  the  treatment  which  strikes  the 
painful  spot.  Thus,  if  pressure  upon  the  prostate  or  upon  the  vesicle 
excites  a  discomfort  which  the  patient  recognizes  as  that  from  which 
he  suffers,  massage  of  these  organs  will  relieve  this  discomfort;  if  the 
passage  of  a  sound  strikes  the  painful  spot,  sounds  are  likely  to  cure; 
if  touching  the  verumontanum  with  a  swab  introduced  through  the  pos- 
terior urethroscope  excites  the  pain,  this  is  likely  to  prove  the  proper 
point  of  attack.  In  these  cases  above  all  others,  care  should  be  taken 
not  to  persist  too  long  in  any  one  course  of  treatment  with  blind  insist- 
ence that  this  treatment  must  cure.  Unless  the  progress  of  the  case  is 
entirely  satisfactory,  no  given  course  of  treatment  should  be  persisted  in 
for  more  than  three  weeks. 

Finally,  so  many  of  these  difficulties  depend  entirely  upon  sexual 
irregularities  and  derangements  that  the  patient's  sexual  habits,  both 
previous  and  present,  should  be  intimately  investigated,  and  every 
effort  made  to  lead  him  to  as  clean,  as  wholesome,  and  as  normal  a 
sexual  condition  as  it  is  possible  for  him  to  attain.  Although  matri- 
mony cannot  be  prescribed  like  a  pill,  and  although  these  patients  are 
often  sorry  subjects  to  place  on  any  woman's  hands,  truly  happy  mar- 
ried life  is  often  the  only  real  remedy  for  the  patient's  condition,  and, 
"unfortunately,  almost  as  often  it  is  a  remedy  beyond  the  patient's 
reach. 

But  the  great  majority  of  urethral  neuroses  arc  due  to  iiilhiimiuition 
in  and  about  the  verumontanum  and  utricle. 

Treatment  of  the  Verumontanum  and  Utricle. — Tlic  urothroscopic 
treatment  of  these  lesions  is  described  on  page  -!0l.  We  niiiy  snni- 
marize  the  status  of  treatment  as  follows : 


248  LOCAL  TREATMENT  OF  CHRONIC  URETHRITIS 

The  sexual  element  is  all-important.  Moral  control  of  the  patient 
is  more  essential  than  physical  treatment.  Mild  measures  may  succeed 
where  severe  ones  fail.  Two  drops  of  10  per  cent  silver  nitrate  solu- 
tion can  be  placed  quite  as  accurately  upon  the  verumontanum  by  the 
instillator  as  by  the  urethroscope.  If  instillations  fail,  the  urethroscope 
may  succeed,  both  by  revealing  lesions,  and  by  permitting  more  severe 
cauterization. 


CHAPTEE    XXVI 
SPASMODIC  AND  CONGENITAL  STRICTURE 

A  LOSS  of  dilatability  of  any  portion  of  the  urethra  constitutes 
stricture.  This  loss  must  be  unnatural,  for  the  urethra  has  certain 
points  of  normal  contraction — namely,  the  meatus,  the  middle  of  the 
pendulous,  and  the  beginning  of  the  membranous  urethra,  and  these  are 
not  strictures.     They  become  so,  however,  if  unduly  small. 

True  stricture  is  of  two  kinds:  (1)  Muscular  or  spasmodic;  (2) 
permanent  or  organic — the  latter  congenital  or  acquired.  Any  inflam- 
mation lessens  the  caliber  of  the  canal  in  proportion  to  the  turgescence 
of  the  mucous  membrane ;  but  no  amount  of  inflammation  constricts 
the  canal  enough  to  occasion  serious  symptoms,  unless  occurring  in 
connection  with  abscess  or  stricture. 

Obstruction  of  the  urethra  by  stone,  slough,  or  foreign  body  does  not 
constitute  stricture. 

MUSCULAR  OR  SPASMODIC  STRICTURE 

Spasmodic  stricture  is  an  involuntary  contraction  of  the  compressor 
urethrae  muscle  of  sufficient  force  to  impede  or  to  prevent,  temporarily 
or  permanently,  the  passage  of  urine  from  the  bladder.  I  have  en- 
countered no  case  of  spasm  of  the  pendulous  urethra,  though  De  Bovis  ^ 
records  two  cases. 

Spasmodic  stricture  is  a  symptom,  not  a  disease.  It  always  depends 
upon  some  separate  and  distinct  condition.  It  varies  with  the  varia- 
tions of  this  etiological  factor  and  disappears  with  its  cure. 

A  common  predisposing  cause  is  a  sensitive,  high-strung  nervous 
organization,  particularly  in  one  who  is  sexually  excessive.  Such  a 
one  is  unable  to  urinate  in  the  presence  of  his  fellows,  and  the  more 
anxious  he  is  to  pass  his  water,  and  the  more  water  there  is  to  pass,  the 
more  difficult  does  he  find  it  to  satisfy  his  desire.  Certain  mental  sug- 
gestions contribute  to  increase  or  to  diminish  the  spasm.  The  sound  of 
running  water  often  breaks  the  spell,  while  derision  or  absolute  silence 
has  the  opposite  effect.  I  have  known  a  commercial  traveler  who,  dur- 
ing twenty  years  of  life  spent  mostly  on  the  road,  could  not  urinate  in 

'-Gas.  des  liop.,  1897,  LXX,  583. 

249 


250  SPASMODIC  AND  CONGENITAL  STRICTURE 

a  railroad  car  except  by  means  of  a  catheter.  Yet  such  a  man  may  well 
go  through  life  with  no  great  inconvenience  from  his  urethral  idiosyn- 
crasy, his  urethrismus,  as  Otis  termed  it.  But  let  him  acquire  an 
organic  stricture  or  a  vesical  calculus,  let  him  be  operated  upon  for 
hemorrhoids,  or  suffer  any  local  or  constitutional  strain  or  shock,  and 
his  urination  immediately  becomes  difficult  or  impossible  to  accomplish 
for  a  greater  or  less  space  of  time.  I  have  known  an  operation  for 
hemorrhoids  to  occasion  complete  retention  lasting  ten  days,  long  after 
the  patient  was  up  and  about.  Such  a  spasm,  if  unrelieved  by  catheteri- 
zation, may  even  cause  rupture  of  the  bladder.  Thus  there  is  this  much 
in  the  theory  of  Otis  that  an  abnormally  small  meatus  may  cause  ure- 
thrismus, that  if  the  meatus  is  small  enough  to  irritate  the  urethra  by 
impeding  urination,  it  may  excite  a  spasmodic  stricture,  though  I  have 
never  known  it  to  do  so. 

Symptoms  and  Diagnosis — The  cardinal  symptom  of  spasmodic 
stricture  is  inability  to  urinate.  Hence,  it  is  sometimes  confounded 
with  organic  stricture.  Indeed,  not  a  few  patients  with  stricture 
deemed  impassable,  when  put  upon  the  operating  table,  have  been  found 
to  admit  a  full-sized  sound,  being  cases  of  spasm  with  little  or  no  organic 
stricture.  The  following  differentiating  points  are  therefore  mem- 
orable : 

1.  Spasmodic  stricture  occurs  only  in  the  membranous  urethra. 

2.  Unless  there  is  some  organic  lesion  of  the  urinary  tract  the  urine 
is  bright  and  sparkling  and  free  from  shreds,  which  it  very  rarely 
is  if  there  is  organic  stricture  sufficiently  marked  to  seriously  arrest 
urination. 

3.  Although  it  may  be  impossible  to  introduce  a  filiform  bougie  or 
a  small  sound,  a  full-sized  sound,  if  allowed  to  rest  for  a  few  moments 
against  the  face  of  the  stricture,  will  usually  tire  the  muscle,  and  finally 
slip  into  the  bladder.  If  it  slips  in  by  its  own  weight  its  course  will 
often  be  jerky  and  irregular,  as  the  muscle  gives  way  by  succeeding 
spasms  of  lessening  intensity. 

4.  When  the  instrument  is  once  introduced  the  obstacle  is  wiped  out, 
and  the  withdrawal  of  the  instrument  is  not  opposed  by  any  such  grasp- 
ing as  is  felt  when  there  is  tight  organic  stricture.^ 

5.  Even  though  a  spasmodic  stricture  be  absolutely  impassable,  gen- 
eral anesthesia  will  entirely  relax  it. 

6.  Organic  and  spasmodic  stricture  often  co-exist.-  Indeed,  organic 
stricture  is  the  most  common  cause  of  spasm,  and  spasm  may  be  the 
notable  symptom  of  an  organic  stricture  of  large  caliber. 

^But  if  the  instrument  passed  is  a  small  one  (less  than  20  F.)  it  does  not  over- 
stretch the  muscle  and  may  therefore  be  grasped  on  withdrawal. 

^  Indeed,  continued  spasm  may  doubtless  cause  ulceration,  just  as  spasm  of  the 
bowel  causes  fissure  in  ano.     (Cf.  Keyes,  Am.  Jour,  of  Urology,  1905^  i.  218.) 


CONGENITAL  STRICTURE 


251 


Treatment. — The  retention  may  be  relieved  by  a  hot  sitz  bath  or  by 
catheterization. 

The  tendency  to  spasm  is  overcome  by  removing  the  canse  and  im- 
proving the  general  hygiene,  special  attention  being  paid  to  sexual 
irregularities,  concentrated  urine,  and  organic  stricture. 

To  prevent  recurrence  of  the  spasm  I  know  nothing  better  than  the 
passage  of  a  full-sized  steel  sound  to  overstretch  the  muscle,  and  silver 
nitrate  instillations  to  blunt  the  sensibility  of  the  deep  urethra. 


CONGENITAL  STRICTURE 


Congenital  strictures,  or  even  total  occlusions  of  the  urethra,  usually 
occur  at  three  places,  though  they  may  occur  anywhere  in  the  canal : 

1.  At  the  meatus. 

2.  At  the  outer  limit  of  the  fossa  navicularis  (internal  meatus)  and 

3.  At  the  membranous  urethra. 

The  stricture  takes  the  form  of  a  valve  or  a  stenosis.  Englisch  rec- 
og-nizes  two  types,  those  that  are  present  during  fetal  life,  but  disap- 
pear later ;  and  those  that  persist.  Such  strictures 
at  any  point  deeper  than  the  internal  meatus  are 
rare  and  usually  cause  death  by  retention,  in  utero 
or  in  infancy.  Bazy  ^  has  however  operated  upon 
several  cases  and  I  have  cut  two. 

On  the  other  hand,  congenital  stricture  at  the 
meatus,  or  at  the  outer  end  of  the  fossa  navicularis 
(aptly  termed  the  second  meatus),  is  very  common. 
Indeed,  the  size  of  the  meatus  is  no  more  fixed  than 
the  size  of  the  mouth  or  the  nose,  though,  in  gen- 
eral, a  small  penis  is  more  likely  to  have  a  con- 
tracted meatus  than  is  a  large  one. 

How  much  contraction  constitutes  stricture  of 
the  meatus  ?  Strictly  speaking,  a  meatus  is  stric 
tured  if  a  probe,  introduced  into  the  fossa  navicu- 
laris and  rotated  so  as  to  sweep  the  point  outward  along  the  floor  of  the 
urethra,  encounters  a  thin  membrane  which  it  must  surmount  in  coming 
out  through  the  meatus.  This  obstruction  always  occurs  on  the  floor  of 
the  canal,  and  is  never  anything  more  than  a  fold  of  mucous  membrane 
that  may  be  pushed  out  by  the  probe  (Fig.  4G).  The  second  meatus  is 
strictured  if  it  is  not  so  large  as  the  nonnal  true  meatus. 

Strictly  speaking,  the  above  rule  holds  good.  Practically,  how- 
ever, stricture  of  the  meatus— to  which  so  many  reflex  ills  were  once 
attributed — rarely  produces  any  symptoms.     If  actually  so  small  as  to 

^Cf.  Neumann,  Zeitschr.  f.  Urol,  1910,  iv,  No.  11. 


Fig.  46.  —  (_  ui\uenital 
Stricture  of  the 
Meatus.  A  probe  is 
inserted  into  the  pock- 
et behind  the  stric- 
ture. 


252  SPASMODIC  AND  CONGENITAL  STRICTURE 

interfere  with  urination  it  may,  perhaps,  like  a  tight  prepuce,  cause 
hernia  or  even  epilepsy  in  a  child,  and  spasmodic  stricture  in  later 
life,  and  the  urethra  may  become  considerably  dilated  behind  it.  But 
such  cases  are  exceptional.  Most  men  can  go  through  life  in  blissful 
igTiorance  of  the  size  of  their  meati  unless  they  acquire  a  urethritis, 
in  which  event  the  stricture  should  be  cut  lest  the  little  pocket  behind 
it  perpetuate  the  inflammation. 

Treatment. — The  only  way  to  cure  a  stricture  of  the  meatus  is  to 
cut  it.  As  above  remarked,  this  is,  as  a  rule,  quite  unnecessary,  except 
for  the  surgeon's  purposes. 

The  operation  of  meatotomy  has  occasioned  the  invention  of  various 
more  or  less  ingenious  meatotomes,  of  which  the  best  is  a  blunt-pointed 
straight  bistoury.  This  is  the  only  instrument  required,  and  the  opera- 
tion may  be  very  neatly  performed  as  follows :  After  cleansing  the 
parts  with  soap,  bichlorid,  and  alcohol,  a  cocain  tablet  is  inserted  within 
the  meatus  and  pressed  into  the  little  pocket  below  it.  This  is  dis- 
solved by  dropping  upon  it  two  drops  of  1 :  1,000  adrenalin  solution. 
In  a  few  moments  the  tip  of  the  meatus  is  seen  to  blanch.  The  bistoury 
is  then  inserted  and  the  membrane  deliberately  divided  upon  a  finger 
placed  beneath  the  frenum,  which  appreciates  the  fibrous  ring  about 
the  meatus  and  at  the  second  meatus,  and  by  feeling  the  blade  of  the 
bistoury  beneath  the  skin  recognizes  when  they  have  been  effectually 
divided.  The  passage  of  a  bulbous  bougie  proves  that  the  obstructions 
have  been  sufficiently  cut.  If  this  technic  is  observed  there  will  be  no 
pain  and  little  bleeding.  The  meatus  is  flushed  clean  and  packed  with 
cotton.  The  cotton  is  removed  at  the  first  act  of  urination,  and  the 
wound  is  kept  open  by  inserting  the  curve  of  a  clean  hairpin  into  the 
urethra  once  a  day.  The  hemorrhage  may  he  profuse  if  no  hemostatic 
applications  are  made,  but  there  are  no  other  complications,  and  lateral 
pressure  will  always  check  the  flow  of  blood. 

Some  surgeons  prefer  to  suture  the  little  wound  in  order  to  hasten 
healing  and  to  prevent  adhesion. 


CHAPTER    XXVIT 

ORGANIC  STRICTURE  OF  THE  URETHRA— ETIOLOGY,  PATHOLOGY, 
SYMPTOMS,   RESULTS,   DIAGNOSIS 

Although  two  conditions  commonly  known  as  stricture  have  been 
described  in  the  preceding  chapter,  the  one,  spasmodic  stricture,  is  a 
mere  symptom,  and  the  other,  congenital  stricture,  a  condition  which, 
except  in  extreme  cases,  is  absolutely  innocuous.  Organic  stricture,  the 
stricture  that  is  never  innocuous  and  always  active  in  its  work  of  under- 
mining its  possessor's  health,  except  when  kept  at  bay  by  the  surgeon's 
efforts,  has  yet  to  be  considered. 

True  organic  stricture  of  the  urethra  is  a  cicatrix  of  the  urethral 
wall  left  there  by  some  injury  or  inflammation,  and  manifesting  a  con- 
stant tendency  to  contract,  and  thus  to  diminish  the  lumen  of  the  ure- 
thra. This  tendency  to  contraction,  which  is  always  manifested  in  a 
greater  or  less  degree,  is  doubtless  caused  by  the  irritation  incident  to 
micturition,  the  impact  of  the  stream  against  the  barrier ;  for  the  deep- 
est stricture,  the  one  that  most  obstructs  the  flow  of  urine,  is  almost 
always  the  tightest,  and  if  the  stricture  is  kept  dilated  so  as  to  afford 
little  or  no  obstruction,  the  tendency  to  recontraction  is  slight. 

Stricture  occurs  in  the  female  as  well  as  in  the  male  urethra.  But 
this  lesion  in  the  female  is  much  less  common  than  in  the  male,  and 
manifests  no  distinguishing  peculiarities,  either  in  pathology,  symp- 
toms, diagiiosis  or  treatment. 

Oberlaender  very  properly  refused  to  recognize  any  pathological 
distinction  between  chronic  anterior  urethritis  and  stricture.  The  patho- 
logical difference  is  only  one  of  degree;  but  the  clinical  distinction  is 
clear.  Infiltrations  larger  than  26  F.  are  readily  cured  by  dilatation 
and  show  but  a  very  slight  tendency  either  to  relapse  or  to  contract. 
But  infiltrations  tighter  than  26  F.  show  a  marked  tendency  to  con- 
tract progressively  and  require  the  treatment  described  in  the  ensuing 
pages  to  cure  or  even  to  control  th^em. 


VARIETIES 

Strictures  may  be  classified  from  several  points  of  view:  thus,  for 
prognostic  purposes,  strictures  are  considered  as  anterior  (at  or  in  front 

253 


254  ORGANIC  STRICTURE  OF  THE  URETHRA 

of  the  penoscrotal  angle)  and  posterior  (behind  this  point)  ;  therapeuti- 
cally considered,  strictures  are  of  large  caliber  (admitting  a  20  F.  bul- 
bous bougie)  or  of  small  caliber ;  while  from  a  pathological  and  etiolog- 
ical point  of  view  strictures  are  classified  as  gonorrheal  and  traumatic. 
The  old  descriptive  division  into  linear,  annular,  and  tortuous  or  irregu- 
lar stricture  is  clinically  convenient  to  describe  the  nature  of  the  ob- 
struction to  the  exploring  instrument,  and  the  terms  soft,  fibrous,  and 
inodular  (or  indurated)  are  descriptive  of  important  features. 


ETIOLOGY 

All  true  strictures  are  either  inflammatory  or  traumatic,  and  almost 
all  inflammatory  strictures  are  gonorrheal. 

By  far  the  greater  number  of  strictures  are  gonorrheal.  Thus  out 
of  220  cases  studied  by  Thompson,  164  (75  per  cent)  owed  their  origin 
to  gonorrhea;  while  Martin  found  among  219  cases  187  gonorrheal 
strictures  (85  per  cent).  -My  ofiic©  case  books  record  583  gonorrheal 
to  43  traumatic  strictures. 

The  causes  of  go7iorrheal  stricture  are,  however,  many.  The  inflam- 
mation itself  usually  causes  the  stricture ;  but  it  is  difiicult  to  estimate 
what  proportion  of  strictures  is  due  to  breaking  a  chordee,  to  a  false 
motion  in  coitus  causing  a  tear  in  the  inflamed  mucous  membrane,  to 
the  ill-advised  use  of  caustic  injections  for  the  purpose  of  aborting  the 
attack,  or  to  the  injudicious  use  of  instruments  in  the  urethra  before 
the  attack  has  subsided.  Such  strictures  are  properly  traumatic,  since 
trauma  of  the  same  kind,  but  greater  in  degree,  may  cause  stricture 
when  the  mucous  membrane  is  not  inflamed  and  the  gonorrhea  thus  only 
plays  the  role  of  a  predisposing  cause. 

There  is  a  small  class  of  intermediate  cases  in  which  the  stricture  is 
neither  absolutely  inflammatory  nor  traumatic.  To  this  class  belong 
strictures  caused  by  urethral  chancres  ^  and  ulcerations,  or  loss  of  sub- 
stance from  periurethritis,  etc. 

The  causes  of  traumatic  stricture  vary  widely.  The  yenile  portion 
of  the  urethra  may  be  divided  by  knife  or  bullet,  or  torn  by  bending  the 
erect  penis,  by  a  false  motion  in  coitus,  or  by  breaking  a  chordee.  The 
hulh  is  the  portion  usually  affected  by  trauma  from  within,  by  ulceration 
from  stone,  foreign  body,  or  retained  catheter,  or  by  the  sharp  point  of 
a  blundering  instrument.  The  prostatic  urethra  is  said  to  become  stric- 
tured  when  torn  by  disruption  of  the  pelvis. 

But  of  all  traumatic  strictures,  recognizable  as  such,  stricture  of  the 
membranous  urethra  is  the  most  frequent.     The  stricture  is  caused  by 

^  Ten  cases  of  diffuse  urethral  syphiloma  have  been  reported.  Gwjon's  Annales, 
1898,  xvi,  892, 


ETIOLOGY  255 

a  crushing  force  applied  to  the  perineum,  whicli  brings  the  urethra 
sharply  into  contact  with  the  suhpul)ic  ligament,  crushing  it  beneath 
the  sharp  edge  of  this  structure  or  tearing  away  from  it  in  front. 

The  injuries  which  have  caused  traumatic  stricture  in  the  perineum, 
with  or  without  a  penetrating  wound,  are  innumerable.  They  may  be 
summarized  in  the  term  "straddle  injuries."  They  may  be  overlooked 
by  the  patient  if  they  do  not  give  rise  to  immediate  hemorrhage  or 
retention.  Yet  in  after  years  symptoms  of  stricture  come  on,  and  the 
canal  is  found  tightly  contracted  at  its  membranous  portion. 

Pathogenesis. — The  most  notable  modern  theories  upon  the  forma- 
tion of  stricture  are  the  theory  of  Finger  and  the  Guyon  school,  and 
the  theory  of  Guiard. 

The  Finger-Guyon  theory  ^  makes  stricture  the  result  of  chronic 
urethritis.  According  to  these  authors,  chronic  urethritis  is  essentially 
a  sclerotic  process,  characterized  by  deposits  of  cicatricial  tissue  in  the 
submucosa  and  even  in  the  corpus  spongiosum.  This  fact  is  illustrated 
by  numerous  pathological  findings  that  would  prove  its  truth  were  it 
not  contradicted  by  the  notorious  clinical  facts. 

For  although,  as  we  have  seen,  acute  urethritis  is  an  exudative  proc- 
ess that  does  tend  to  pass  into  a  chronic  sclerotic  stage,  the  essential  cause 
of  the  exudation  is  the  acuteness  of  the  attack  and  the  extent  of  exuda- 
tion, and  subsequent  cicatrization  is  proportional  rather  to  the  acuteness 
of  the  attack  than  to  its  duration.  Hence,  although  stricture  is  always 
accompanied  by  chronic  anterior  urethritis,  chronic  anterior  urethritis 
may  exist  for  years  without  inducing  stricture. 

We  therefore  accept  Guiard's  theory,^  that  stricture  depends  iipon 
the  virulence  of  the  urethral  inflammation.  The  more  severe  the  initial 
attack,  the  more  intense  the  chordee,  the  more  frequent  and  violent  the 
relapses,  and  the  longer  the  gonococcus  can  be  found  in  the  discharge, 
the  greater  is  the  probability  of  stricture.  He  believes  that  in  a  mild 
chronic  stage  the  urethral  inflammation  is  neither  deepseated  nor  pro- 
ductive of  any  permanent  lesion ;  while  the  acute  inflammation,  with  its 
involvement  of  the  lacunae  and  glands,  its  circumscribed  or  diffused 
areas  of  periurethritis,  is  the  inflammation  calculated  to  leave  behind 
permanent  scars  in  and  beneath  the  mucous  membrane. 

In  the  etiology  of  traumatic  stricture  urinary  infiltration  must  play 
some  part.  It  is  true,  severe  contusion  and  laceration  of  the  urethral 
wall  are  ample  causes  for  stricture ;  but  it  is  incredible  that  the  muscular 
disturbance  of  urination  and  the  distention  of  the  wound  with  a  fluid 
containing  urinary  salts  and  urethral  bacteria  should  cause  no  increase 

^Finger,  Internat.  Idin.  Rundsclum,  February  12,  1893.  Wasserniann  and  Hall§, 
Guyon' s  Annales,  1891,  ix,  143  et  passim.  Wassermanu  and  Ilalle,  Ihid.,  1894,  xii, 
244,  321. 

*"Les  urethrites  chroniqucs  chez  I'liommc. "     Paris,  1898,  p.  90  et  seq. 


256  ORGANIC  STRICTURE  OF  THE  URETHRA 

in  the  inflammatory  reaction.  The  admirable  results  obtained  by 
simple  perineal  section  and  diverbion  of  the  stream  of  urine  from  the 
wound  confirm  this  belief. 

In  this  connection  the  time  of  occurrence  of  stricture  after  gonorrhea 
and  injury  is  of  interest.  Of  the  164  cases  of  stricture  following  gon- 
orrhea, tabulated  by  Thompson,  in  10  symptoms  appeared  immediately 
after  or  during  the  attack ;  71  within  one  year ;  41  between  three  and 
four  years;  22  between  seven  and  eight  years;  20  between  eight  and 
twenty-five  years.  Hill  ^  makes  the  length  of  the  period  between  the 
cause  and  the  first  symptoms  of  stricture  noticed :  after  gonorrhea,  short- 
est period  two  years,  longest  thirteen  years ;  after  urethral  chancre, 
shortest  period  ten  months,  longest  three  years;  after  injury,  shortest 
period  four  months,  longest  eighteen  months.  I  found  among  212  cases 
of  gonorrheal  stricture  121  cases  within  the  first  year,  65  distributed 
between  the  second  and  tenth  years,  and  26  after  the  tenth  year.  On  the 
other  hand,  I  have  seen  an  impassable  stricture  in  the  perineum  six 
weeks  after  a  severe  injury,  and  Guy  on  ^  has  met  a  stricture  which  only 
admitted  a  16  F.  sound  two  weeks  after  injury,  and  another  which 
would  not  admit  a  12  F.  after  six  weeks. 

The  deductions  from  the  above  statistics,  confirmed  by  daily  observa- 
tion, are  that  the  symptoms  of  stricture  appear  earlier  after  traumatism 
than  after  gonorrhea  (the  date  of  their  appearance  being  measurably 
proportionate  to  the  extent  of  the  injury)  and  that  the  greatest  di- 
vergence is  noticeable  after  gonorrhea.  It  is  totally  exceptional,  how- 
ever, for  symptoms  of  organic  stricture  to  come  on  immediately  after  or 
during  the  attack  of  gonorrhea — as  Thompson  states  occurred  in  ten  of 
his  cases — unless  stricture  existed  previous  to  the  attack,  unnoticed  by 
the  patient. 

PATHOLOGY 

Number  of  Strictures. — While  Thompson,^  in  examining  270  patho- 
logical specimens,  found  only  44  cases  of  multiple  stricture,  Guyon  '^  lays 
down  the  clinical  rule  that  gonorrheal  strictures  are  multiple,  while 
traumatic  strictures  are  single.  These  statements,  properly  interpreted, 
conform  perfectly  with  each  other  and  with  the  facts.  Concerning  trau- 
matic strictures,  there  is  no  doubt ;  they  are  almost  always  single.  But 
gonorrheal  strictures,  while  frequently  single  from  the  pathologist's 
point  of  view,  often  present  a  number  of  ridges  to  the  examining  sound. 

»"An  Analysis  of  One  Hundred  and  Forty  Cases  of  Stricture  of  the  Urethra." 
London,  1871. 

^ ' '  Lemons  cliniques, ' '   1894,  vol.   i,  p.   239. 

'"Stricture  of  the  Urethra."    Second  edition,  1858,  p.  76. 

*0p.  cit.,  I,  139. 


PATHOLOGY 


257 


^  Indies 


Clinically,  therefore,  gonorrheal  strictures  are  often  multiple,  patho- 
logically they  are  usually  single. 

Seat  of  Stricture. — Thompson  divides  the  urethra  into  three  regions : 

1.  The  bulbomembranous,  including  1  inch  in  front  of  and  f  inch 
behind  the  junction  of  the  spongy  with  the  membranous  urethra. 

2.  From  the  anterior  limit  of  region  1  to  within  2^  inches  of  the 
meatus,  embracing  from  2|  to  3  inches  of  the  spongy  urethra. 

3.  The  first  2-J  inches  of  the  canal  from  the  meatus. 

His  270  preparations  showed  320  strictures:  67  per  cent  in  region 
1 ;  16  per  cent  in  region  2 ;  17  per  cent  in  region  3. 

Otis  placed  a  majority  of  all  strictures  within  the  first  1 
from  the  meatus — the  next  most  common  posi- 
tion being  somewhere  in  the  middle  portion  of 
the  pendulous  urethra.  He  believed  deep 
urethral  stricture  to  be  far  less  common;  but 
these  views  depended  upon  his  theory  that  the 
urethra  is  a  tube  evenly  calibrated  throughout. 
Therefore  the  points  of  physiological  narrow- 
ing or  of  non-contracting  infiltration  left  by 
urethritis  (p.  161)  he  denominated  stricture. 

It  is  convenient  to  associate  the  region  in 
which    the    stricture    occurs    with    its    cause. 
Thus,  strictures  at  or  near  the  meatus,  if  not 
congenital,  are  usually  caused  by  chancrous  or 
chancroidal  ulceration,  less  frequently  by  caus- 
tic injections  and  by  gonorrhea.     Strictures  of 
the  pendulous  urethra   are  commonly  gonor- 
rheal.    Strictures  of  the  bulb  and  at  the  bulbomembranous  urethra  are 
also  commonly  gonorrheal.     Strictures  of  the  membranous  urethra  are 
rarely  gonorrheal,  almost  always  traumatic.     Stricture  in  the  prostatic 
urethra  may  be  gonorrheal  or  traumatic. 

Form  of  Stricture. — In  the  first  place,  the  stricture  is  usually  chiefly 
built  up  from  the  floor  of  the  canal.  This  is  most  notable  in  the  bulb, 
and  commonly  results  in  an  eccentric  position  of  the  orifice  of  the 
stricture,  close  to  the  upper  wall  of  the  canal.  The  cause  is  not  far  to 
seek.  It  is  in  the  loose  floor  of  the  canal,  especially  in  the  pocket  of  the 
bulb,  that  the  gonococci  commit  their  greatest  ravages.  It  is  the  floor 
of  the  canal  that  is  most  often  torn  or  crushed.  It  is  the  floor  of  the 
canal  that  is  damaged  by  overdistention,  when  urination  is  obstructed. 

In  the  second  place,  it  is  a  matter  of  clinical  experience  that  in  the 
broad,  irregular  strictures  that  are  clinically  multiple,  the  const lictions 
become  progressively  narrower  as  they  approach  the  bladder.  Uogi li- 
ning, perhaps,  at  the  penoscrotal  angle,  there  is  a  constriction  which 
admits  a  20  F.  sound.     A  short  distance  farther  on  this,  .too,  is  ob- 


FiG.  47  — Stricture  of  An- 
terior Urethra.  (Voil- 
lemier.) 


258 


ORGANIC  STRICTURE  OF  THE  URETHRA 


structed,  and  only  a  15  F.  will  pass,  and  finally  the  stricture  in  the 
bulb  admits  only  a  filiform  instrument.  In  other  words,  the  deeper 
extremity  of  the  stricture,  which  receives  the  strongest  impact  of  urine, 

is  more  irritated  than  the  rest  and  contracts  more  rapidly. 

Gross  Pathological 
'/-  "^v,,:,/^if  Changes  (Eigs.  47, 
48,  49).— When  the 
strictured  urethra  is 
slit  longitudinally, 
the  mucous  mem- 
brane may  be  found 
only  slightly  thick- 
ened and  congested. 
Or  it  may  be  cicatri- 
cial in  character  or 
covered  with  granu- 
lations. A  band  or  a 
mass  of  cicatrix  may 
replace  the  mucous 
membrane  through- 
out its  thickness,  and 
may  even  penetrate 
the  corpus  spongio- 
sum. This  tissue 
may  be  slight  in  ex- 
tent, cicatricial  in 
character,  tightly 
contracted ;  or  it 
may  be  exuberant, 
knobbed,  and  exces- 
sive in  amount,  so  as 
to  be  readily  felt 
from  the  outside  of 
the    canal.      In    this 

callous,  fibrous  mass  there  may  be  irregular  areas  of  inflammation  and 

suppuration.     Behind  the  stricture  the  canal  is  distended  and  more  or 

less  extensively  ulcerated,  and  immediately  in  front  of  the  stricture 

there  may  be  lesser  dilatations  and  ulcerations. 

If  the  retention  has  been  prolonged  and  grave  the  upper  urinary 

organs  show  the  results  of  retention  and  infection  illustrated  in  Fig. 

49  and  described  on  p.  2"' 
Microscopic  Changes. 


Fig.  48. — Stricture  of  Membranous  Urethra.  (Voille- 
mier.)  A,  bladder;  B,  bladder  neck  (ecchymotic) ;  C,  di- 
lated prostatic  urethra;  D,  verumontanum ;  E,  one  of  the 
prostatic  ducts;  F,  G,  K,  the  stricture;  F,  dilatations  in  front 
of  the  tightest  part  of  the  stricture;  H,  orifice  of  small 
abscess  cavity ;  K,  mucous  membrane  in  front  of  the  stric- 
ture, thin  and  ulcerated;  L,  corpus  spongiosum;  M,  an- 
terior urethra. 


-These  have  been  described  (p.  160). 


Fig.  49. — Re.sults  of  Stricture.  A,  A',  Kid= 
neys  dilated,  sclerosed,  pyonnphrotic;  B,  B', 
ureters  irregularly  dilated;  C,  bladder  con- 
tracted and  thickened  (concentric  hyper- 
trophy); D,  dilated  ureteral  orifice;  E,  pros- 
tatic urethra  dilated  (prostatic  abscess); 
F-H,  the  stricture;  F,  its  tightest  point;  G, 
corpora  cavernosa  involved  iu  the  scar. 


259 


260  ORGANIC  STRICTURE  OF  THE  URETHRA 


SUBJECTIVE    SYMPTOMS 

Organic  stricture  may  exist  for  years,  producing  no  symptoms  and 
unsuspected.  On  the  other  hand,  the  usual  symptoms  of  stricture, 
gleet,  the  irregular  stream  of  urine,  and  the  final  dribble,  are  of  daily 
occurrence  among  men  who  have  not,  and  never  had,  stricture. 

The  Onset — Symptoms  occur  within  one  year  in  over  half  the  cases, 
though  one-quarter  of  them  show  no  symptoms  until  after  five  years 
have  elapsed,  and  the  onset  may  be  deferred  for  15  years  or  even 
longer.  But  only  one-third  of  my  (private)  cases  submitted  to  treat- 
ment within  a  year  of  the  beginning  of  their  symptoms ;  another  third 
within  five  years ;  and  one-seventh  delayed  treatment  until  their  symp- 
toms had  existed  for  10  or  more  years.-*^ 

Gleet — The  initial  symptom  is  usually  the  presence  of  shreds  (Trip- 
perfdden)  and  more  or  less  free  pus  in  the  urine.  If  the  stricture 
follows  immediately  after  a  gonorrhea  the  urethral  discharge  is  per- 
petuated; but  more  often  there  is  a  lull  while  the  shreds,  and  perhaps 
the  general  cloudiness  of  urine,  persist,  but,  in  the  absence  of  a  notable 
gleet,  do  not  attract  the  patient's  attention.  The  shreds  and  pus  are 
evidence  of  the  local  inflammation  on  the  stricture,  which  is  adding 
fuel  to  the  flame,  and  encouraging  extension  and  contraction  of  the 
fibrous  tissue  beneath. 

As  the  stricture  contracts  the  urethritis  grows  worse  and,  sooner  or 
later,  produces  a  moderate  chronic  discharge,  perhaps  only  visible  in 
the  morning  when  the  urethra  has  not  been  scoured  by  the  urinary 
stream  for  eight  hours,  perhaps  persisting  throughout  the  day.  This 
is  gleet.  It  is  usually  the  first  symptom  noted  by  the  patient.  The 
gleet  of  stricture  gets  better  or  worse  according  to  the  general  condition 
of  the  patient,  the  degree  of  acidity  of  the  urine,  and  the  amount  of 
sexual  indulgence  or  of  venereal  excitement.  Exacerbations  of  gleet 
from  slight  causes,  or  repeated  attacks  of  gonorrhea,  as  the  patient 
usually  considers  them,  often  constitute  the  most  marked  feature  of 
the  case.  In  fact,  it  is  the  rule  in  mild  cases  for  the  patient  to  be  wholly 
unconscious  that  his  urethra  is  at  all  narrowed.  Gleet  was  the  initial 
symptom  of  238  of  my  cases. 

Changes  in  the  Stream — As  the  stricture  tightens,  fresh  symptoms 
are  added.  The  gleet  continues,  the  stremn  of  urine  is  small  and  irregu- 
lar.^    The  last  few  drops  of  urine  are  retained  in  the  canal,  both  me- 

^  Trans.  Am.  Assn.  G.-U.  Surg.,  1915,  x,  11. 

"  It  is  to  be  noted  that  while  an  impediment  anywhere  in  a  water-pipe  (such  as 
the  urethra)  modifies  the  force  of  the  stream,  the  shape  of  the  stream  depends  chiefly 
upon  the  shape  of  the  nozzle  (the  meatus).  Thus  the  shape  of  the  stream,  upon 
which  so  much  stress  is  commonly  laid,  has  no  bearing  on  the  diagnosis  of  stricture. 
It  is  modified  by  the  meatus  itself  more  often  than  by  any  other  cause. 


RESULTS  OF  STRICTURE  261 

chanically  by  the  obstruction  of  the  stricture,  and  because  the  wave  of 
blood,  impelled  by  the  contraction  of  the  accelerator  urinae  upon  the 
bulb  in  the  final  efl^ort  at  clearing  the  canal,  cannot  pass  along  the 
corpus  spongiosum,  on  account  of  the  obliteration  of  its  meshes  at  the 
point  of  stricture,  and  thus  fails  in  its  function  of  expelling  the  last 
few  drops  of  urine  from  the  canal.  By  this  same  obliteration  of  spongy 
tissue,  erection  is  sometimes  rendered  imperfect  and  painful.  Ob- 
structed urination  was  the  first  symptom  in  77  of  my  cases. 

Frequent  Micturition — Next  to  gleety  discharge  frequency  of  mic- 
turition is  the  commonest  symptom  of  stricture.  It  is  due  to  one  or 
all  of  the  following  factors,  viz. :  congestion  from  straining  to  overcome 
the  urethral  resistance,  cystitis,  polyuria  due  to  renal  congestion. 

With  the  frequency  there  is  more  or  less  pain.  This  was  the  initial 
symptom  in  61  of  my  cases. 

Retention. — The  congestion  of  the  stricture  may  be  kindled  by 
a  heavy  dinner,  a  little  excess  in  drink,  or  a  chilling  of  the  legs;  the 
mucous  membrane  swells,  the  stricture  closes,  and  acute  retention  of 
urine  results.  If  this  retention  is  unrelieved,  the  bladder  becomes  over- 
stretched, and  the  case  progresses  like  an  acute  prostatic  retention  (p. 
294). 

Retention  may  be  the  only  prominent  symptom.  The  gleet  may  not 
have  been  noticed,  the  gradual  decrease  in  the  size  of  the  stream  may 
have  been  ignored,  when,  after  exposure,  excess,  or  a  carouse  of  beer, 
retention  suddenly  comes  on.  Such  was  the  procedure  in  31  of  my 
cases. 

Hematuria. — Exceptionally  hematuria  may  be  the  most  prominent 
symptom  of  stricture,  indeed  the  only  one  noticed  by  the  patient. 
(This  happened  3  times  in  my  series.)  The  bleeding  comes  from  an 
ulcerated  spot  and  may  be  quite  profuse.  The  blood  usually  continues 
to  drip  after  the  close  of  micturition  (urethrorrhagia). 

Pain. — Pain  on  urination  is  due  to  prostatitis,  cystitis,  or  retention. 
The  pain  is  felt  at  the  neck  of  the  bladder,  in  the  perineum,  at  the 
point  of  stricture,  or  near  the  glans  penis. 

Sexual  Symptoms. — Excepting  the  impotence  which  results  from 
grave  stricture,  all  the  other  sexual  symptoms  that  have  been  tradition- 
ally accredited  thereto  are  actually  referable  to  prostatitis,  vesiculitis, 
or  verumontanitis. 

RESULTS  OF  STRICTURE 

Hemorrhoids  and  Hernia — The  constant  straining  in  urination 
keeps  the  henierrhoidal  vessels  congested.  This  not  infrequently  results 
in  an  attack  of  piles  or  of  rectal  prolapse;  occasionally,  hernia  occurs 
from  the  same  cause. 


262 


ORGANIC  STRICTURE  OF  THE  URETHRA 


Prostatitis,  Vesiculitis,  Epididymitis. — Prostatitis,  vesiculitis,  and 
epididymitis  are  common  results  of  stricture. 

Cystitis. — The  inflammation  of  the  bladder  caused  bj  stricture  is 
usually  superficial,  but  it  may  become  parenchymatous.  In  neglected 
cases  the  bladder  usually  becomes  concentrically  hypertrophied  (p.  367). 
When  this  concentric  hypertrophy  is  of  long  standing  the  contracted 
bladder  does  not  dilate  with  relief  of  the  stricture:  the  frequency  of 
urine  persists  unabated. 

Stone. — Urinary  calculus  is  a  rare  result  of  stricture. 

Pyelonephritis.^Infection  and  dilatation  of  the  ureters  and  kid- 
neys occur  as  in  prostatic  retention. 


RESULTS  OF  THE  MALTREATMENT  OF  STRICTURE 


The  results  of  the  maltreatment  of  stricture  are  hemorrhage,  inflam- 
mation of  the  stricture  itself,  periurethritis,   infection  of  the  upper 

urinary    tract,    and 


false  passage.  Of 
these  only  the  last 
requires  detailed 
mention  here. 

False  Passage. — 

False  passage  results 
from  the  rough  or 
unskillful  use  of 
small  instruments  in 
an  obstructed  ure- 
thra (Fig.  50). 

The  surgeon 
making  a  false  pas- 
sage may  be  uncon- 
scious of  the  escape 
of  the  point  of  his 
instrument  from  the 
canal,  but  he  soon 
perceives  that  it  is 
behaving  unusually. 
It  is  obstructed,  but 
The  point,  moreover, 


False  Passage.     (Dittel.) 


yet  not  held  as  though  in  the  grasp  of  a  stricture 
seems  often  to  be  turned  out  of  the  median  line,  and,  after  the  instru- 
ment has  been  introduced  far  enough  to  reach  the  bladder,  a  rotary 
motion,  imparted  to  the  shaft,  will  show  that  the  point  is  fixed  in  the 
connective  tissue,  and  not  freely  movable,  as  it  would  be  in  the  cavity 


RESULTS  OF  NEGLECTED  STRICTURE  263 

of  the  bladder.  In  sucli  a  case  a  finger  in  the  rectum  will  feel  the  point 
of  the  instrument  just  outside  the  wall  of  the  gut,  at  the  apex  of  the 
prostate,  or  perhaps  lying  between  the  prostate  and  the  gut.  On  with- 
drawing the  instrument,  blood  flows  freely  from  the  meatus. 


RESULTS  OF  NEGLECTED  STRICTURE 

In  view  of  recent  researches,  many  of  the  fundamental  notions  con- 
cerning infiltration  of  urine  have  been  completely  changed,  and  this 
condition  and  its  associated  phenomena  now  appear  as  inflammatory  and 
not  as  mechanical  complications  of  stricture.  Since  the  time  of  Voille- 
mier  the  accepted  theory  has  been  that  all  urethral  dilatations  and  uri- 
nary pouches  in  the  region  of  a  stricture,  as  well  as  all  urinary  extrav- 
asation and  infiltration,  are  due  to  the  pressure  of  the  urine  forced 
against  the  weakened,  inflamed  urethra  by  the  bladder  filled  to  over- 
flowing. The  urine  was  supposed  to  burst  through  the  urethra,  and 
thus  to  cause  these  complications.  But  a  certain  number  of  phenomena 
are  unexplained  by  this  hypothesis.     These  are : 

1.  Urethral  dilatations,  abscesses  and  urinary  pouches  in  front  of 
the  stricture.     Such  cannot  be  caused  by  any  urinary  pressure. 

2.  Urinary  extravasation  or  gangrene  caused  by  strictures  of  large 
caliber,  when  the  back  pressure  is  by  no  means  sufiiciently  violent  to 
cause  rupture  of  the  urethra. 

Moreover,  in  direct  contradiction  to  the  theory  of  acute  extrav- 
asation are  the  observed  facts  that : 

1.  The  more  the  bladder  is  distended  the  less  able  is  it  to  exert  any 
great  force  or  to  produce  more  than  a  dribbling  stream,  even  after  the 
urethral  right  of  way  has  been  re-established. 

2.  When  a  urinary  pocket  is  opened,  and  its  urethral  orifice  found, 
the  urine  never  gushes  out,  but  flows  drop  by  drop. 

Indeed,  Escat  ^  and  Cottet  ^  go  so  far  as  to  deny  that  the  clinical 
picture  of  mechanical  extravasation  exists.  The  terrible  straining  and 
agony  suddenly  relieved  with  a  feeling  of  something  giving  away  in  the 
perineum,  and  soon  followed  by  extravasation,  is,  it  would  seem,  a 
description  devised  to  fit  a  theory. 

The  inflammation  assumes  one  of  the  following  types: 
1.  Suppuration   within   the   stricture   causes   periurethral   abscess, 
which : 

a.  Kemains  localized  and  quiescent. 
h.  Is  absorbed. 

''Guyon's  Annates,   3898,  xvi,   897   and   1026.      This  article  is  a   detailed   and 
brilliant  elucidation  of  the  whole  subject. 
==  Ihid.,  1899-  xviii,  590. 


264  ORGANIC  STRICTURE  OF  THE  URETHRA 

c.  Extends  into  the  perineum  and  scrotum. 

d.  Opens  into  the  urethra  and — 

1.  Discharges  and  heals. 

2.  Remains  as  a  fibrous  sac  filled  continuously  or  intermit- 

tently with  urine,  and  communicating  with  or  shut 
off  from  the  urethra.      {Urinary  pouch.) 

3.  Fills  with  urine  and  bacteria,  whose  ravages  rapidly 

spread  the  infection,  causing  infiltration,   extravasa- 
tion, plilegmon,  abscess,  or  gangrene. 

2.  Suppuration  on  the  surface  of  the  sclerotic  tissue,  usually  behind, 
sometimes  at,  and  rarely  in  front  of  the  stricture,  may  cause  dilatation 
of  the  urethra,  periurethritis,  periurethral  abscess  (with  the  associated 
lesions  just  noted),  or,  if  the  physical  and  bacterial  conditions  are  ap- 
propriate,-^ gangrene  of  the  urethra  alone  or  of  the  surrounding  tissues 
as  well. 

3.  To  fill  out  and  complete  the  theory  that  these  accidents  depend 
solely  upon  the  combination  of  individual  predisposition  and  bacterial 
virulence,  two  other  conditions  may  be  explained  by  it :  the  one,  malig- 
nant gangrene  of  the  genitals,  a  spontaneous  gangrene  extending  over 
the  genitals,  sparing  the  deeper  tissues,  terminating  in  recovery,  occur- 
ring in  young  subjects  with  genito-urinary  history  or  disease,  and  quite 
comparable  to  noma,  though  not  fatal ;  the  other,  genital  gangrene  of  old 
prostatics  long  habituated  to  catheter  life,  a  similar  condition,  not  dia- 
betic in  origin,  terminating  in  death  (Guy on  and  Albarran,  quoted  by 
Escat).  These  rare  conditions  can  arise  from  no  source  other  than  a 
fortuitous  combination  of  soil  and  seed,  comparable  to  that  presented 
by  gangrenous  extravasation. 

Periurethritis. — In  almost  any  long-strictured  urethra  there  can 
be  felt,  by  introducing  a  sound  and  palpating  the  canal  against  it,  ir- 
regular masses  of  cicatricial  tissue  occupying  more  or  less  of  the  whole 
length  of  the  canal.  A  sensitive  nodule  in  this  mass  indicates  an  area 
of  periurethral  inflammation  that  may,  at  any  time,  develop  into  an 
abscess. 

Periurethral  Abscess — With  the  onset  of  suppuration  in  this  tis- 
sue there  is  a  sharp,  septic  febrile  reaction.  The  lump  gTOws  rapidly 
larger,  more  painful,  and  tender,  and  it  may  encroach  upon  the  urethra 
sufficiently  to  cause  retention.  Ultimately  it  opens  into  the  urethra,  or 
passes  into  a  chronic  stage,  or  more  commonly  extends  into  the  peri- 
neum, burrowing  thence  throughout  the  subcutaneous  tissue  of  the  ex- 
ternal genitals,  the  thighs,  the  groins,  and  even  to  the  lower  belly,  dis- 

^Cottet  quotes  Veillon  and  Zuber's  law:  "No  gangrene  or  putrefaction  with- 
out anaerobic  bacteria,"  and  finds  in  all  the  cases  examined  by  him  that  when 
anaerobic  bacteria  were  present  there  was  gangrene,  and  when  they  were  absent,  even 
with  extensive  infiltration,  there  was  no  gangrene. 


EESULTS  OF  NEGLECTED  STRICTURE  265 

chargiBg  at  many  points,  and  leaving  the  whole  region  a  mass  of 
fistulae,  through  which  the  urine  escapes,  perhaps  not  one  drop  passing 
by  the  natural  channel.  In  these  cases  the  patient  makes  water  sitting, 
the  urine  escaping  as  though  through  the  sprinkler  of  a  watering-pot. 
Civiale  reported  such  a  case  with  fifty-two  external  openings. 

Urinary  Infiltration  (Periurethral  Phlegmon,  or  Gangrene). — Be- 
ginning as  an  acute  or  a  chronic  periurethral  abscess,  or  as  a  gangrene  of 
the  urethral  wall,  the  acute  infective  process  rapidly  spreads  over  the 
perineum  and  the  genitals.  The  first  sign  is  a  tender  edematous  swelling 
in  the  median  line  of  the  perineum,  which  rapidly  increases  in  size  and 
spreads  superficially  in  every  direction.  If  there  is  gangrene  this 
spreads  with  frightful  rapidity.  If  there  is  not  gangrene,  the  enormous 
edematous  swelling,  which  may  reach  the  size  of  a  child's  head,  breaks 
up  into  innumerable  foci  of  suppuration,  from  which  pus,  and,  later,  pus 
and  urine  pour  out.  Accompanying  all  this  are  shock,  severe  septic 
symptoms,  and  usually  retention  of  urine. 

It  is  usual  in  these  cases  for  the  tumor  to  be  extensively  infiltrated 
with  urine,  and  to  contain  one  or  more  irregular  central  cavities  filled 
with  urine,  necrotic  tissue,  and  pus;  but  there  may  be  no  appreciable 
infiltration  nor  any  communication  with  the  urethra,  and  urethrotomy 
without  a  guide  may  be  required  for  the  purpose  of  relieving  the  re- 
tention. 

The  bladder  never  becomes  gangrenous,  though  the  urethra  slough 
to  its  very  neck.  The  suppuration  and  gangrene  may  leave  a  urethro- 
rectal fistula,  but  the  cavity  of  the  pelvis  is  never  invaded. 

Inasmuch  as  urinary  infiltration  generally  occurs  in  debilitated  per- 
sons, and  is  itself  a  very  virulent  septic  process,  it  often  terminates 
fatally. 

Urinary  Fistula. — The  periurethral  abscess  may  open  and  dis- 
charge in  remote  regions,^  but  it  usually  opens  in  the  perineum. 

The  internal  orifice  is  usually  single,  however  many  the  outward 
openings.  The  fistula,  if  long  and  tortuous  or  branched,  contains  diver- 
ticula which  repeatedly  close,  form  abscesses,  and  discharge;  or  they 
may  contain  foreign  bodies  or  calculi,  or  the  entire  tract  may  be  in- 
crusted  with  calculus. 

PROGisrosis. — Blind  internal  fistulae  tend  to  close  unless  there  is 
stricture.  If  they  persist,  they  may  form  the  starting-point  for  abscess 
or  infiltration. 

Blind  external  fistulae  close  spontaneously,  or  after  cauterization  or 
curettage. 

Complete  fistulae  usually  require  operation. 

^Desnos  mentions  a  urinary  fistula  opening  at  the  lower  angle  of  the  scapula. 
I  have  seen  one  that  reached  the  loin. 


266  ORGANIC  STRICTURE  OF  THE  URETHRA 


DIAGNOSIS 

Inasmiicli  as  stricture  is  only  an  accentuation  of  the  pathological 
process  that  constitutes  chronic  anterior  urethritis,  it  may  be  diagnosed 
by  the  bulbous  bougie.  Any  infiltration  larger  than  26  F.  may  be 
termed  "chronic  urethritis,"  if  smaller,  "stricture."  But  inasmuch 
as  the  tendency  to  contract  is  the  essential  feature  of  stricture,  I 
prefer  the  sound  to  the  bougie  and  term  "stricture"  only  such  infiltra- 
tions as  grasp  the  sound  (see  below). 

There  are  certain  points  in  the  history  and  urinary  signs  that  are 
peculiarly  suggestive. 

History. — A  history  of  prolonged  mild  intermittent  gleet  is  pecul- 
iarly suggestive  of  stricture.  Spontaneous  urethrorrhagia  is  suggestive 
of  stricture.  .Retention  of  urine  is  due  either  to  stricture,  prostatism, 
or  paralysis  of  the  bladder. 

The  Urine. — Large  shreds  in  the  urine  are  an  indication  of  local- 
ized hard  infiltrations  in  the  anterior  urethra,  actual  or  potential  stric- 
tures. These  shreds  may  be  obscured  by  free  pus;  but  unless  the 
stricture  is  controlled  by  treatment  the  urine  always  contains  more  or 
less  shreds. 

Diagnosis  of  Impassable  Stricture. — ^When  a  filiform  bougie  cannot 
be  passed  to  the  bulbous  urethra,  there  is  impassable  stricture. 

If  the  bougie  reaches  the  bulb  but  will  not  enter  the  membranous 
urethra,  the  obstruction  is  either  stricture  or  spasm.  An  attempt  is 
then  made  to  pass  the  largest  sound  that  will  enter  the  meatus.  If 
this  is  passed  gently  into  the  bulbous  urethra  and  held  against  the  face 
of  the  obstruction,  it  overcomes  the  contraction  of  spasm  but  absolutely 
fails  to  pass  the  stricture. 

DIFFERENTIAL  DIAGNOSIS 

So  much  for  the  method  of  examination.  The  presence  of  an  ob- 
struction having  been  determined,  the  differential  diagnosis  lies  between 
organic  stricture,  spasm,  and  chronic  inflammation.  The  position  of  the 
obstruction  and  the  various  points  dwelt  upon  in  the  preceding  para- 
graphs, and  in  the  chapter  on  Spasm,  are  elements  in  the  diagnosis. 
But  the  most  distinguishing  characteristic  of  all  is  resiliency.  Organic 
stricture  is  always  elastic  and  resilient,  the  others  are  not.  To  test 
this  resiliency  a  sound — the  largest  that  will  pass — is  gently  introduced 
through  the  supposed  stricture.  It  is  allowed  to  rest  in  place  for  a 
moment,  and  then  an  attempt  is  made  to  withdraw  it.  //  there  he  or- 
ganic stricture  the  withdrawal  of  the  instrument  will  he  opposed  hy  a 
firm  grasping  as  long  as  the  instrument  remains  engaged  in  the  stric- 


DIAGNOSIS 


267 


tiire.      If,  however,  there  be  no  grasping  there  is  no  organic  stric- 
ture. 

To  tabulate  these  features  briefly : 


Shreds  or  pus. 

Obstruction . . . 
Grasping 


Organic  Stricture. 


Always  present. 

Always  present. 
Always  present. 


Spasm. 


Not  present  unless  there  is  an 

inflammation. 
Only  in  membranous  urethra. 
No. 


Urethritis. 


Present. 

Sometimes. 
No. 


CHAPTER   XXVIII 

STRICTURE  OF  THE  URETHRA:  PROGNOSIS  AND 
TREATMENT 

PROGNOSIS 

The  prognosis  of  stricture  ^  depends  upon  the  treatment  more  than 
upon  any  other  one  thing,  but  varies  according  to  the  nature  and  loca- 
tion of  the  scar.  Traumatic  strictures  often  contract  rapidly,  in  spite 
of  treatment.  Gonorrheal  strictures,  on  the  other  hand,  contract  far 
less  energetically.  Strictures  of  the  perineal  urethra  are  far  more  diffi- 
cult to  cure  than  strictures  of  the  pendulous  urethra.  The  latter  con- 
tract slowly  and  are  commonly  curable  by  urethrotomy;  the  former 
contract  more  rapidly  and  are  incurable — that  is,  they  may  be  relieved 
by  sounding  or  urethrotomy,  but  they  almost  inevitably  relapse  after 
a  time.  Finally,  the  more  extensive  a  stricture,  the  more  irregular  its 
surface,  and  the  denser  the  cicatricial  tissue  composing  it,  the  more  diffi- 
cult will  be  its  treatment  and  the  more  dubious  its  cure. 

In  the  matter  of  life  or  death,  however,  the  prognosis  of  stricture  is 
far  less  gloomy.  Stricture  is  very  rarely  fatal,  except  in  neglected  cases. 
Death  occurs  in  various  ways. 

1.  Periurethral  phlegmon,  which,  if  extensive,  kills  at  once  by  shock, 
or,  later,  by  exhaustion,  suppuration,  abscess,  gangTene,  or  pyemia. 

2.  Urinary  septicemia,  the  retention  resulting  in  pyelonephritis  or 
pyonephrosis.  The  patient  may  die  from  such  a  cause  even  after  the 
stricture  has  been  dilated,  or,  as  is  more  commonly  the  case,  the  treat- 
ment itself,  whether  by  sound  or  knife,  may  induce  urinary  septicemia 
which  closes  the  scene. 

3.  Sudden  death  following  the  passage  of  a  sound.  Such  deaths 
are  extremely  rare,  and  are  apparently  due  either  to  the  use  of  cocain, 
to  status  lymphaticuSj  or  to  nervous  shock  upon  an  impaired  heart. 

TREATMENT 

Enlarge  the  urethra  hy  dilatation,  aided,  if  necessary,  by  cutting. 
Then  maintain  its  caliber  by  dilatation.     Or  perhaps  the  negative  view 
^Cf.  Trans.  Am.  Assn.,  G.-U.  Sxirg.,  1915. 

268 


TREATMENT  269 

is  more  forcible.  Never  cut  if  you  can  dilate;  and  recognize  that  the 
patient  is  not  cured  unless  he  stays  cured.  Cutting  is  at  best  a  substitute 
for  dilatation,  while  divulsion  and  electricity  are  no  substitutes. 


PROPHYLAXIS 

Since  most  strictures  are  caused  by  gonorrhea,  and  the  occurrence 
of  gonorrheal  stricture  is  favored  by  the  intensity  and  the  duration  of 
the  inflammation,  every  effort  made  to  control  this  inflammation  is  so 
much  toward  the  prevention  of  a  possible  stricture.  Yet  this  is  but  an 
indirect  prophylaxis,  since  it  is  impossible  to  prophesy  which  case  of 
gonorrhea  will  terminate  in  stricture  and  which  will  not.  But  when 
the  disease  becomes  chronic  in  the  anterior  urethra^  although  there  be 
no  stricture  present,  the  inflammation  is  encouraged  by  and  is  in  turn 
encouraging  a  periurethral  sclerosis,  which  may  develop  into  a  veritable 
stricture.  Therefore,  intelligent  treatment  of  anterior  urethritis  is 
the  surest  preventive  of  stricture. 

For  traumatic  stricture  the  proper  prophylaxis  is  immediate  peri- 
neal section  at  the  time  of  injury  (p.  528). 

CURATIVE  TREATMENT 

Since  the  sound  is  the  instrument  best  adapted  to  the  cure  of  stric- 
ture, and  since,  unfortunately,  it  is  easier  to  use  a  sound  wrongly  than 
rightly,  a  few  words  on  the  use  and  effects  of  sounds  are  required. 

The  surgeon  attacking  a  stricture  of  the  urethra  may  fairly  analyze 
the  therapeutic  problem  thus :  "Here  is  a  scar  with  a  congested  surface ; 
shall  I  cut  or  shall  I  massage  it  ?"  If  he  cuts  through  it  the  symptoms 
are  relieved,  the  obstruction  is  apparently  removed,  but  the  scar  is  still 
there.  In  fact,  there  is  rather  more  scar  than  ever,  and  if  the  former 
scar  contracted  and  gave  trouble,  so  much  the  more  will  this  one.  To 
prevent  this  he  will  keep  the  lips  of  the  wound  separated  by  sounds,  so 
that  it  may  heal  with  so  broad  an  insertion  band  that  the  contraction 
will  be  of  no  moment.  Such  a  course  will  succeed  in  the  pendulous 
urethra ;  but  if  the  stricture  is  in  the  perineal  urethra  and  of  such 
density  as  to  give  the  shadow  of  an  excuse  for  cutting,  it  will  certainly 
relapse  after  the  operation  unless  subjected  to  systematic  massage  by 
sounds.  The  knife  only  relieves  the  congestion  plus  a  temporary  relief 
of  the  contraction,  while  the  sound  actually  causes  the  resorption  of 
the  exudate.  The  effect  is  quite  comparable  to  the  effect  of  massage 
applied  to  the  outside  of  the  body.  Moreover,  the  maximum  of  effect 
is  produced  by  the  minimum  of  effort,  or,  as  Guyon  puts  it,  "the  effect 
is  due,  not  to  the  pressure  of  the  sound,  but  to  its  mere  contact." 

It  is  a  matter  of  everyday  experience  that  the  brutal  passage  of  a 


270  STRICTURE  OF  THE  URETHRA 

sound,  bruising  and  tearing  the  congested  urethra,  is  followed  by  a  sharp 
inflammatory  reaction,  which  increases  rather  than  diminishes  the  exu- 
date. Such  treatment  is  inexcusable.  The  stricture  is  already  con- 
gested, the  mucous  membrane  already  inflamed.  What  more  futile  pro- 
cedure than  to  add  irritation  to  irritation!  Such  is  not  the  object  of 
the  sound.  On  the  contrary,  the  sound,  if  a  metal  one,  should  slip  in 
almost  by  its  own  weight ;  slowly  indeed,  but  surely.  Such  a  maneuver 
has  the  treble  efi^ect  of  lessening  congestion  at  the  point  of  contact, 
straightening  out  irregularities  in  the  canal,  and  stimulating  the  deeper 
tissues  to  a  favorable  reaction,  which  will  result  in  softening  the  cica- 
trix. But  to  do  this  the  sound  must  press  without  bruising.  If  a  given 
sound  will  not  pass,  try  a  smaller  one.  The  effect  is  readily  judged.  If 
a  sound  is  properly  introduced,  it  may  usually  be  followed  by  sounds  of 
the  next  larger  sizes  with  less  pain  than  the  first.  Larger  sounds  may 
be  introduced  at  each  sitting;  the  rapid  amelioration  of  the  symptoms 
shows  that  the  congestion  is  relieved,  the  obstruction  is  disappearing, 
and  the  canal  is  resuming  its  normal  condition.  Yet,  however  gently  a 
sound  is  introduced,  it  will  be  followed  within  forty-eight  hours  by  a 
congestive  reaction  of  more  or  less  intensity.  Hence,  in  treating  stric- 
ture by  dilatation  it  is  bad  surgery  to  introduce  instruments — unless 
filiforms — before  the  lapse  of  seventy-two  hours,  and  even  longer  in- 
tervals will  often  produce  better  results. 

Lastly,  and  above  all,  gently,  gently,  geisttlt! 

TREATMENT    OF    VARIOUS    KINDS    OF    STRICTURE 

The  treatment  of  stricture  at  the  meatus  and  of  spasmodic  stricture 
has  been  dealt  with.  Apart  from  these,  the  treatment  of  stricture  may 
be  considered  under  the  following  captions : 

1.  Stricture  of  large  caliber. 

2.  Stricture  of  small  caliber. 

3.  Stricture  admitting  only  a  filiform. 

4.  Stricture  complicated  by  retention. 

5.  Impassable  stricture. 

6.  Traumatic  and  resilient  stricture. 

7.  Stricture  complicated  by  prostatitis.      (Irritable  stricture.) 
8o  Stricture  complicated  by  false  passage. 

9.  Stricture  complicated  by  periurethritis  or  prostatic  abscess. 

10.  Stricture  complicated  by  fistula. 

11.  Stricture  complicated  by  acute  pyelonephritis. 

1.  Treatment    of    Uncomplicated    Stricture    of    Large    Caliber . 

After  the  diagnosis  has  been  made  by  the  passage  of  a  bulbous  bougie, 
no  further  instrumentation  is  advisable  (if  the  patient  can  spare  the 
time)  until  the  effect  of  exploration  has  been  observed.    The  chances  of 


TREATMENT  271 

uretliral  chill  after  the  first  examinations  must  be  remembered.  The 
patient's  general  condition  and  habits  must  be  studied,  and  his  urine 
tested  for  acidity  or  possible  kidney  disease.  He  must  be  instructed  in 
urethral  hygiene,  the  nature  of  his  malady  must  be  explained,  and,  to 
forestall  future  disappointment,  he  should  be  informed  at  the  outset 
that,  after  his  symptoms  have  been  relieved  by  treatment,  the  per- 
manence of  his  cure,  if  his  stricture  is  deep  in  the  urethra,  may  depend 
upon  his  use  of  an  instrument  upon  himself  at  proper  intervals,  in  order 
to  prevent  recontraction. 

Being  instructed  not  to  mind  the  smarting  at  his  next  urination,  a 
few  drops  of  silver  nitrate  are  instilled,  and  the  patient  is  instructed  to 
take  a  tablet  of  hexamethylenamin  after  each  meal  and  to  return  in  two 
days  for  dilatation. 

Sounds. — The  treatment  best  adapted  to  the  majority  of  these  cases 
is  dilatation  with  a  conical  double  taper  steel  sound.  One  of  these  in- 
struments properly  warmed  and  sterilized  is  introduced  in  the  manner 
already  detailed.  Its  size  should  correspond  to  that  of  the  bougie  that 
has  passed  the  stricture,  and  the  utmost  delicacy,  care,  and  gentleness 
should  be  used  in  its  introduction.  As  soon  as  the  instrument  has  en- 
tered the  bladder  it  should  be  gently  withdrawn  at  once.  IS^othing  is 
gained  by  leaving  it  even  for  a  moment.  During  withdrawal  the  stric- 
ture is  usually  felt  to  grasp  the  sound.  After  one  sound  has  been  with- 
drawn, a  second  and  even  a  third  may  be  introduced,  if  considered  safe. 
It  may  be  stated  as  a  rule,  subject  to  judicious  exception,  that  if  a  coni- 
cal steel  instrument  of  any  size  larger  than  No.  15  F.,  when  held  m 
proper  position,  will  not  enter  a  stricture  almost  by  its  own  weight 
after  a  little  delay,  it  should  not  he  used.  Every  urethra,  however, 
has  its  own  temper;  some  are  aroused  by  the  slightest  disturbance, 
while  others  bear  considerable  violence  without  protest.  A  surgeon 
should  acquaint  himself  by  gradual  experiment  with  the  temper  of  a 
given  urethra  before  he  takes  liberties  with  it. 

The  mischief  to  be  feared  from  the  employment  of  large  sounds  with 
force  (besides  false  passage,  which  is  not  likely  to  be  produced  by  large 
instruments)  is  threefold: 

1.  Epididymitis,  a  common  result  of  violence  to  the  urethra,  and 
a  complication  which  suspends  treatment  and  confines  the  patient  to  bed 
for  several  days  or  weeks. 

2.  Infiammation  in  the  stricture,  which  aggravates  its  condition  and 
defeats  the  end  of  the  treatment. 

3.  Chill  and  urethral  fever. 

The  third  danger,  the  chill  and  fever,  is  very  unusual  after  manipu- 
lation of  the  pendulous  urethra — witness  the  impunity  with  which  many 
surgeons  cut  far  and  wide  through  that  part  of  the  long-suifering  canal 
— and  increases  as  we  approach  the  bulbomembranous  junction.     Some 


272  STRICTURE  OF  THE  URETHRA 

persons  have  a  predisposition  in  this  regard,  and  the  presence  of  some 
renal  lesion  is  essential  as  a  predisposing  cause  of  any  i-eal  septic 
chill.  Yet  in  no  given  case  can  the  prognosis  be  definite,  and  the  only 
safety  lies  in  hedging  the  operation  about  with  all  possible  precautions. 

The  rule  which  I  have  found  most  efficacious  is : 

Hexamethylenamin  before, 

Gentleness  during, 

Nitrate  of  silver  or  permanganate  of  potassium  after  sounding. 

At  each  subsequent  visit  of  the  patient,  the  surgeon  commences  with 
a  sound  from  one  to  two  sizes  smaller  than  the  last  instrument  intro- 
duced at  the  previous  visit,  and  carries  the  dilatation  as  far  as  possible 
without  the  employment  of  force,  till  the  full  size  is  reached. 

The  Interval. — The  most  important  feature  in  the  treatment  of 
stricture  by  dilatation  is  a  proper  regulation  of  the  intervals  to  be  al- 
lowed between  the  visits.  The  intervals  usually  recommended  are  too 
short.  We  can  only  repeat  that  it  is  bad  surgery,  in  treating  stricture 
hy  dilatation,  to  reintroduce  instruments — unless  filiforni — before  the 
lapse  of  at  least  seventy-two  hours,  and  even  longer  intervals  will 
often  produce  better  results. 

The  Full  8ize. — As  to  the  degree  of  dilatation  which  is  to  be  aimed 
at,  every  urethra  has  its  own  gauge  in  the  size  of  its  meatus — provided 
that  meatus  be  not  congenitally  small,  or  contracted  by  disease.  If 
there  is  any  cicatricial  tissue  in  the  circle  of  the  meatus,  or  if  a  probe 
can  make  out  any  pouching  below  the  lower  commissure  (Fig.  46),  the 
meatus  is  too  small. 

In  the  majority  of  cases  this  physiological  gauge- — the  normal 
meatus — is  adequate.  A  stricture  once  dilated  to  this  size — which  will 
vary  from  27  to  32  F. — will  stand  the  test  of  a  cure — that  is,  the  in- 
flammation about  it  (not  necessarily  the  prostatitis)  will  rapidly  dis- 
appear, and  the  stricture  will  not  recontract  during  the  lengthened 
intervals  of  sounding  that  constitute  the  after-treatment.  But  occa- 
sionally the  meatus  is  too  small  a  gauge.  The  outer  fibers  of  the  scar  lie 
so  deep  and  are  so  elastic  that  they  are  unaffected  by  the  pressure  and 
tend  to  recontract  as  soon  as  the  lengthened  intervals  of  sounding  pennit 
them  to  do  so.  Such  strictures  must  be  cut  or  stretched  with  the  Koll- 
mann  dilator  until  a  point  is  reached  where  they  do  not  recontract.^ 

*  Otis  's  Theory. — Such  was  the  basis  of  Otis 's  famous  theory.  Meeting  many 
strictures  incurable  by  the  half-hearted  methods  of  dilatation  then  in  vogue,  and 
finding  that  a  generous  incision  cured  stricture  of  the  anterior  urethra,  he  evolved 
the  theory  that  the  urethra  is  an  evenly  calibrated  tube  whose  size  bears  a  direct 
relation  to  that  of  the  flaccid  penis.  This  ratio  he  fixed  at  10  mm.  of  urethral 
circumference  to  every  inch  of  penile  circumference.  Thus,  a  3-inch  penis  should 
take  a  30  F.;  a  3%-inch  penis  a  34  F.  The  objection  to  Otis's  theory  is  that  it  is 
incorrect.  The  urethra  is  no  more  an  evenly  calibrated  tube  than  the  ureter,  the 
esophagus,  or  the  bowel.    Its  size  no  more  varies  with  that  of  the  penis  than  does  the 


TREATMENT  273 

Dilators. — There  is  iio  question  but  that  sounds  of  a  size  readily 
admitted  by  the  meatus  may  be  passed  with  less  discomfort  to  the  pa- 
tient than  any  dilator.  But  if  the  stricture  when  dilated  to  the  size  of 
the  meatus  recontracts  with  undue  rapidity,  further  dilatation  may  be 
performed  by  the  Kollmann  dilator.  This  instrument  is  employed  in 
the  same  manner  as  in  the  treatment  of  chronic  urethritis. 

Ueetheotomy. — If  at  any  stage  of  dilatation  the  stricture  rebels 
and  can  not  be  dilated  any  further,  urethrotomy  must  be  resorted  to. 

Choice  of  Urethrotomy. — External  section  is  best  suited  to  strictures 
of  the  bulb,  internal  section  to  strictures  of  the  pendulous  urethra. 
There  still  remains  a  choice  of  instruments  for  internal  urethrotomy, 
which  choice  is  simply  a  matter  of  taste.  For  my  part,  I  like  the 
bistoury  for  strictures  near  the  meatus,  Otis's  dilating  urethrotome  for 
any  stricture  of  the  pendulous  urethra  large  enough  to  admit  that  in- 
strument, and  Maisonneuve's  urethrotome  only  for  those  strictures 
through  which  an  Otis  instrument  will  not  pass. 

After-tkeatment. — The  after-treatment  depends  upon  the  loca- 
tion of  the  stricture. 

//  the  stricture  is  in  the  'pendulous  urethra,  the  surgeon  may  feel 
confident  that  a  cure  persisting  three  months  will  prove  permanent. 
When  the  stricture  has  been  dilated  fully,  so  that  there  are  no  longer  any 
large  shreds  in  the  urine  (unless  from  the  posterior  urethra),  the  patient 
may  be  dismissed  to  report  in  two  weeks.  If  at  that  time  there  is  no 
recontraction,  he  may  be  dismissed  for  a  month,  and  again  for  two 
months,  when  his  cure  may  be  pronounced  permanent.  If,  however, 
there  is  a  relapse  on  any  of  these  occasions,  visits  must  be  renewed, 
and  the  patient's  cure  insured  by  higher  dilatation  or  a  further  cutting. 

If  the  stricture  is  in  the  bulb  the  matter  is  different.  In  all  such 
strictures,  except  those  soft  bands  that  yield  to  one  or  two  passages  of  a 
sound,  recontraction  will  almost  inevitably  take  place,  unless  the  cure 
be  maintained  by  the  passage  of  a  full-sized  sound.  This  is  easily  done 
by  the  patient.  In  a  few  lessons  he  acquires  the  art  of  gently  passing  a 
sound  upon  himself,  and  he  should  be  seriously  cautioned  to  perform 
this  trifling  but  important  operation  once  or  twice  a  year.  If  the  sound 
fails  to  pass  on  some  such  occasion  he  must  report  for  examination.  In 
this  way,  in  some  cases,  the  use  of  instruments  may  be  gradually  aban- 
doned; in  the  majority,  it  will  have  to  be  continued  indefinitely,  at 
intervals  varying  from  a  week  to  a  year.  Thus  the  6ure  becomes  radical. 
The  surgeon  is  responsible  for  the  cure  only  on  condition  that  the  pa- 
size  of  the  esophagus  with  that  of  the  neck.  The  objection  to  Otis's  practice  is 
that  it  involves  an  unnecessary  and  harmful  amount  of  cutting,  since,  as  a  rule, 
the  patient  can  get  well  without  it,  and  the  operation  may  leave  a  canal  defective 
in  expulsive  power.  Moreover,  though  this  wide  cutting  cures  strictures  of  the 
pendulous  urethra,  it  does  not  cure  deep  strictures. 


274  STRICTURE  OF  THE  URETHRA 

tient  carries  out  this  plan ;  or,  rather,  the  patient  is  responsible  for  the 
permanence  of  his  own  cure,  and  this  he  must  be  made  distinctly  to 
understand. 

2.  Stricture  of  Small  Caliber. — To  this  class  belong  strictures 
admitting  any  instrument  less  than  No.  15  F.  They  are  considered 
separately,  not  because  they  require  different  treatment,  but  in  order  to 
emphasize  the  fact  that  they  are  better  treated  with  soft  than  with  steel 
instruments.  The  danger  of  making  a  false  passage  in  an  obstructed 
urethra  with  a  small  metallic  instrument  cannot  be  overrated.  ISTo  one 
can  appreciate  the  ease  with  which  a  false  passage  is  made  until  he 
has  himself  made  one.  Indeed,  a  surgeon,  not  well  acquainted  with  the 
urethra,  may  make  a  false  passage,  and  go  on  dilating  it  instead  of  the 
stricture,  wondering  meantime  that  the  size  of  the  stream  is  not  in- 
creased or  the  symptoms  alleviated.  Only  a  surgeon  who  knows  every 
line  of  the  urethra  may  occasionally  assume  the  risk  of  using  a  small 
metallic  instrument  in  the  canal  without  a  guide. 

Dilatation  is  carried  on  as  already  directed,  steel  instruments  being 
used  as  soon  as  the  stricture  will  admit  ISTo.  15. 

Ueetheotomy. — Cutting  may  be  resorted  to: 

a.  If  the  stricture  will  not  dilate. 

h.  If  the  patient  has  not  the  time  to  go  through  a  long  course  of 
dilatation. 

c.  If  urethral  fever  follows  all  attempts  at  dilatation. 

3.  Stricture  Admitting"  Only  a  Filiform,  but  Not  Complicated  by- 
Retention. — It  may  be  impossible  to  enter  the  bladder  with  any  instru- 
ment, either  on  account  of  the  tightness  of  the  stricture,  or  because 
the  point  of  the  instrument  does  not  engage  in  the  latter,  or  is  arrested 
by  some  fold  beyond.  In  these  cases  gentle  perseverance  and  skill  will 
rarely  fail  of  success. 

Pkeliminaey  Measures. — The  very  failure  of  larger  instruments 
to  pass,  which  tells  us  that  filiforms  must  be  employed,  so  distorts  the 
orifice  of  the  stricture  as  to  make  the  passage  of  filiforms  most  difficult. 
Consequently  only  one  or  two  brief  efforts  should  be  made  at  this  time. 
If  these  fail  further  efforts  should  be  deferred  for  forty-eight  hours. 

As  a  preliminary  the  urethra  should  be  injected  with  anesthetic 
lubricant.     This  is  preferable  to  oil  or  adrenalin. 

Introdtjction  of  Filiforms. — Filiforms  (p.  22)  are  apt  to  catch 
in  the  urethral  folds  and  crypts  both  in  front  of  and  behind  the  stricture. 

The  following  maneuvers  are  employed  to  overcome  this  diffi- 
culty : 

1.  When  an  instrument  catches,  partially  withdraw  and  slightly 
rotate  it,  pushing  it  forward  while  making  the  rotatory  movement.  This 
device  rarely  fails  in  finally  engaging  the  instrument  in  the  orifice  of 
the  stricture,  especially  if  the  filiform  point  be  bent  or  twisted  so  that 


TREATMENT 


275 


Fig.  51. — -Introduction  of  Fili- 
FORMS.  (Bryant.)  a,  guide 
bent  upward;  h,  guide  in  lac- 
una; c,  numerous  guides  in 
urethra,  one  passing  stricture. 


its  extremity  may  lie  outside  of  the  axis  of  the  shaft  of  the  instru- 
ment. 

2.  An  excellent  method  of  finding  the  orifice  of  a  stricture  consists 
in  cramming  the  urethra  full  of  filiform  bougies,  engaging  their  points 
in  all  the  lacunae  and  false  passages,  and  then  trying  them,  one  after 
another,  until  that  one  is  pushed  forward  which  is  presenting  at  the 
orifice  of  the  stricture,  when  it  will  at  once  engage  (Fig.  51). 

3.  If  the  point  of  the  filiform  passes  the  stricture  but  catches  in  the 
prostatic  urethra,  it  may  be  lifted  into  the 
bladder  by  a  finger  introduced  into  the 
rectum. 

A-.  Where  filiforms  fail  a  10  F.  ure- 
thral sound  may  pass  by  virtue  of  its  curve. 
Only  the  expert  surgeon  may  employ  such 
an  instrument  with  impunity. 

5.  If  the  stricture  is  a  single  band  the 
face  of  which  may  be  reached  by  the  ure- 
throscope, this  instrument  is  introduced, 
the  stricture  wiped  with  adrenalin  until  it 
ceases  to  bleed,  and  a  filiform  then  intro- 
duced, guided  by  direct  ocular  observation. 
This  maneuver  rarely  succeeds  where  other  means  fail. 

Aftek-tkeatment. — After  a  filiform  has  been  introduced  the  stric- 
ture is  dilated  to  10  or  12  F.  When  the  patient  is  next  seen,  two  days 
later,  a  10  F,  bougie  will  usually  pass,  or  we  may  have  to  resort  to 
filiforms   again. 

If  drainage  of  the  upper  urinary  tract  is  deemed  necessary,  a  fili- 
form may  be  tied  in  (p.  6Y3). 

4.  Retention. — Acute  retention  requires  immediate  relief.  The 
patient  should  be  placed  in  a  hot  bath,  more  hot  water  being  added 
after  he  has  become  accustomed  to  the  first  heat,  and  this  carried  as 
high  as  bearable.  He  should  remain  in  the  bath  from  fifteen  to  twenty 
minutes,  and  should  attempt  to  empty  his  bladder  while  in  the  water. 
If  the  heat  is  sufficient  to  induce  nausea  or  faintness,  it  is  more  likely 
to  produce  the  desired  effect  of  relaxing  the  stricture.  Following  this 
relief  an  attempt  at  dilatation  should  be  made  as  described  in  the  pre- 
ceding section. 

If  these  expedients  fail,  the  bladder  may  be  aspirated  every  eight 
hours  for  one  day  or  drained  by  suprapubic  puncture  (p.  713).  Then 
the  patient  is  put  into  a  hot  bath  for  twenty  minutes  and  a  final  attempt 
made  to  introduce  a  filiform.  This  failing,  the  stricture  may  be  fairly 
considered  impassable. 

In  drawing  the  urine  from  a  distended  bladder  it  is  well  not  to  re- 
move more  than  •''jOO  c.c.  (§  xvj)  at  a  time.     If  there  is  more  than  this, 


276  .    STRICTURE  OF  THE  URETHRA 

draw  off  tlie  remainder  after  twenty  minutes.  Too  quick  emptying  of 
an  acutely  distended  bladder  has  been  followed  by  hemorrhage,  collapse, 
and  even  sudden  death. 

5.  Impassable  Stricture. — Ho  stricture  (congenital  atresia  ex- 
cepted) is  impervious  unless  the  urethra  has  been  cut  across  and  all 
the  urine  escapes  behind  the  cut,  or  unless  the  urine  escapes  through 
large  fistulae.  If  a  drop  of  urine  can  pass,  the  stricture  is  pervious. 
Our  inability  to  pass  instruments  is  due  to  the  crookedness,  not  to  the 
tightness,  of  the  stricture. 

How  far  the  surgeon  shall  continue  coaxing  the  urethra  before  re- 
sorting to  external  urethrotomy  without  a  guide  is  a  matter  to  be  decided 
on  the  merits  of  each  individual  case.  If  the  patient  is  difficult  to 
manage,  and  there  is  fear  that,  once  relieved  from  his  present  necessity, 
he  may  not  submit  to  treatment,  it  is  a  kindness  to  take  advantage  of 
his  misfortune  by  insisting  upon  perineal  section  at  once. 

But  external  perineal  urethrotomy  without  a  gTiide  is  a  difficult 
operation,  and  is  not  to  be  undertaken  lightly.  If  it  is  the  patient's 
first  retention,  if  he  was  previously  passing  a  fair-sized  stream,  and  if 
the  bladder  is  not  already  too  full,  it  is  always  well  to  try  palliative 
measures.  But,  on  the  other  hand,  it  is  not  wise  to  fritter  away  time  to 
the  permanent  detriment  of  the  patient's  bladder  and  kidneys  when  a 
stroke  of  the  knife  would  solve  the  difficulty.-^ 

6.  Traumatic  and  Other  Resilient  Strictures — Traumatic  strictures 
close  down  with  great  rapidity  and  are  very  rebellious  to  treatment. 
They  are  resilient.  When  dilated  ever  so  little  they  recontract  and  often 
are  made  worse,  rather  than  better,  by  sounds.  Under  such  conditions 
dilatation  is  a  losing  game.  The  knife  must  be  used.  When  the  scar 
is  linear,  simple  perineal  section  will  suffice  to  render  it  amenable  to 
the  sound.  When,  as  is  often  the  case,  the  scar  is  annular  and  fibrous, 
all  the  scar  tissue,  both  on  roof  and  floor,  must  be  cut  away.  The  urethral 
wound  may  need  to  be  closed  by  suture  or  graft,  but  that  does  not 
signify :  the  scar  must  be  removed  at  all  costs,  since  it  never  loses  its 
retractile  quality,  and  simple  section  will  be  followed  by  a  recontraction 
almost  as  rapid  as  after  the  original  injury.  Cabot's  resection  (p.  734) 
is  the  ideal  operation  for  such  cases. 

Other  resilient  strictures  must  be  dealt  with  similarly. 

7.  Stricture  Complicated  by  Prostatitis  {Irritable  Stricture). — 
Strictures  classed  as  irritable  in  reality  present  no  peculiar  irritability 
in  themselves,  but  they  are  complicated  by  prostatitis.  As  soon  as  the 
point  of  the  sound  or  the  bougie  passes  well  through  the  stricture  it 
glides  over  the  prostatic  urethra,  the  really  irritable  point — though,  be 

^  Special  instruments,  such  as  Sinclair 's  retrograde  cystoscope,  devised  to  obviate 
urethrotomy  without  a  guide,  are  so  rarely  needed  that  their  use  will  never  become 
general. 


TREATMENT  277 

it  understood,  only  the  minority  of  strictures  complicated  by  prostatitis 
are  irritable — and  provokes  an  exacerbation  of  the  prostatic  inflamma- 
tion or  a  sharp  chill.  When  such  a  complication  presents  itself  the 
simplest  solution  is  perineal  section;  but  this  is  not  always  essential. 
By  bracing  the  patient's  general  health,  by  employing  rather  large 
doses  of  hexamethylenamin,  by  using  the  utmost  gentleness  in  sounding, 
by  preferring  bougies,  which  are  less  violent  to  the  prostatic  urethra 
than  sounds,  or  else  blunt  sounds  whose  points  need  not  enter  the 
prostate  at  all,  and  by  treating  the  stricture  only  sufficiently  to  permit 
local  treatment  of  the  prostatitis  until  the  latter  is  materially  improved 
— by  such  means  operation  may  often  be  avoided. 

8.  Stricture  Complicated  by  False  Passage. — The  treatment  for  a 
fresh  false  passage  is  to  let  it  absolutely  alone  for  two  weeks,  if  the 
patient  can  urinate,  and  is  in  no  pressing  need  of  relief.  Blood  will 
flow  for  a  day  or  two,  then  pus  for  a  few  days,  and  at  the  end  of 
two  weeks,  in  favorable  cases,  the  passage  opened  by  the  instrument  will 
often  have  closed. 

In  avoiding  an  old  false  passage,  the  seat  of  chronic  suppuration,  its 
position  must  be  accurately  studied,  by  observing  at  what  point  in  the 
urethra  an  instrument  engages  in  it,  and  from  which  wall  of  the  canal 
(upper  or  lower  ^)  it  starts. 

The  orifice  of  a  false  passage  once  accurately  located,  may  be  sub- 
sequently avoided  by  making  an  effort  to  present  the  beak  of  the  instru- 
ment at  a  different  portion  of  the  canal  when  passing  the  dangerous 
point. 

If  repeated  attempts  fail,  or  if  suppuration  and  periurethritis  inter- 
vene, perineal  section  should  be  performed  without  delay. 

9.  Stricture  Complicated  by  Periurethritis. — There  is  no  sane  pal- 
liative treatment  of  periurethritis  and  its  complications.  The  simple 
inflammatory  areas  should  be  treated  by  methodical  soundings,  perhaps 
aided  by  hot  sitz  baths  and  leeches  to  the  perineum.  Under  such  a 
course  they  rapidly  suppurate  or  disappear. 

Peeiurethkal  or  Prostatic  Abscess  requires  prompt  evacuation 
and  drainage  by  median  perineal  incision.  The  urethra  should  be 
opened  and  the  stricture  cut.  In  dealing  with  small  abscesses  this  is 
a  simple  matter.  Large  ones  should  be  cut  and  drained  like  infiltra- 
tions. 

Infiltration  of  Urine  demands  immediate  and  radical  incision. 
The  patient's  life  is  entirely  in  the  surgeon's  hands.  Timorous  incision 
is  the  patient's  death-warrant.     The  infiltrated  area  must  be  slit  open 

^  Guyon  states  that  he  never  met  a  false  passage  on  the  roof,  hence  advises 
following  that  wall  of  the  urethra  to  avoid  it.  I  have,  however,  met  two  cases  of 
false  passage  on  the  roof,  as  shown  by  external  urethrotomy,  and  have  seen  one  other 
with  the  urethroscope. 


278  STRICTURE  OF  THE  URETHRA 

from  end  to  end.     JSTecrotic  tissue  must  be  sacrificed  with  no  thought  of 
ultimate  disfiguration. 

10.  Stricture  Complicated  by  Fistula — The  chief  aim  in  the  treat- 
ment of  fistula  is  to  remove  the  impediment  to  urination — to  dilate  the 
stricture.  This  done,  the  fistula  may  close.  If  it  fails  to  heal  promptly, 
perineal  urethrotomy  should  be  performed. 

11.  Stricture  Complicated  by  Acute  Pyelonephritis. — The  kidney 
must  be  drained  either  by  a  retained  catheter  or  by  perineal  section. 
The  tube  should  remain  in  place  until  the  temperature  touches  normal. 
This  failing,  nephrotomy  is  required. 

SUMMARY  OF  TREATMENT  OF  STRICTURE 

1.  Hexamethylenamin,  sedatives,  alkalies,  and  rest  are  serviceable 
in  some  cases  of  stricture;  indispensable  if  there  be  any  serious  com- 
plication. 

2.  All  uncomplicated  strictures,  not  highly  irritable  or  resilient, 
should  be  treated  by  dilatation  w^ith  soft  instruments  up  to  ISTo.  15  T., 
and  with  conical  steel  sounds  afterwards — reintroductions  being  made 
every  fourth  day. 

3.  Until  well  acquainted  with  the  temper  of  a  given  stricture,  every 
sounding  should  be  preceded  by  hexamethylenamin,  followed  by  nitrate 
of  silver. 

4.  Dilatation  need  rarely  be  carried  beyond  the  caliber  of  the 
normal  meatus. 

5.  Any  stricture  resisting  dilatation  must  be  cut. 

6.  For  the  pendulous  urethra,  internal  urethrotomy.  For  the  peri- 
neal urethra,  external  urethrotomy  or  the  combined  operation. 

7.  In  general,  anterior  stricture  of  the  urethra  is  curable,  deep 
stricture  of  the  urethra  incurable. 

8.  Impassable  stricture  without  retention  may  usually  be  overcome 
with  filiform  bougies  by  time,  patience,  and  skill.  If  finally  proved 
impassable,  the  treatment  is  external  perineal  urethrotomy. 

9.  Retention  is  treated  by  hot  baths ;  these  failing,  by  aspiration,  or 
by  external  urethrotomy  without  a  guide. 

10.  Traumatic  strictu.re  may  be  prevented  by  section  at  the  time  of 
injury.     Once  having  shown  itself,  it  usually  requires  resection. 

11.  Eesilient  and  inodular  strictures  are  best  treated  by  resection. 

12.  Irritable  strictures  may  often  be  cured  without  cutting. 

13.  Acute  inflammatory  complications  usually  call  for  operation. 

14.  Unless  secondary  retention  has  occurred  in  the  ureter  or  renal 
pelvis,  drainage  of  the  bladder  by  division  of  the  stricture  will  relieve 
an  acutely  infected  kidney. 


CHAPTEK    XXIX 
THE  PROSTATE:  ANATOMY,  PHYSIOLOGY— PROSTATISM 

ANATOMY 

The  prostate  is  a  sexual  organ,  partly  glandular,  partly  muscular, 
lying  in  front  of  the  bladder  and  surrounding  the  prostatic  urethra 
(Figs.  52,  65). 

In  sliape  the  prostate  is  an  irregular  truncated  cone.  It  has  been 
aptly  compared  to  a  horse-chestnut.  Its  apex  rests  against  the  posterior 
layer  of  the  triangular  ligament.  Its  base,  toward  the  bladder,  is 
pierced  above  by  the  urethra,  below  by  the  ejaculatory  ducts.  Its  up- 
per (anterior)  and  lateral  surfaces  are  rounded,  its  lower  (posterior) 


Fig.  52. — Sagittal   Section  of  Prostate,  Bladdek  Neck  and  Membranous   Urethra. 

Division  of  gland  by  urethra  and  ejaculatory  ducts  well  shown. 

279 


280  THE  PROSTATE 

surface  presents  a  boss  on  each  side  of  the  median  line.  It  is  to  this 
lower  surface  particularly  that  the  title  heart-shaped  or  chestnut-shaped 
applies. 

The  diameters  of  the  prostate,  as  given  by  von  Frisch  ^  (and  Thomp- 
son ^)  are:  length,  33  to  45  mm.  (25  to  30  mm.)  ;  width  at  the  base, 
34  to  51  mm.  (32  to  40  mm.)  ;  thickness,  13  to  24  mm.  (20  to  25  mm.). 
Its  weight  is  16  to  24  grams.  In  position  it  is  8  to  12  mm.  below  the 
symphysis,  and  its  apex  is  30  to  40  mm.  from  the  anus.  Its  long  axis 
makes  an  angle  of  20  to  25  degrees  with  the  perpendicular. 

The  prostate  is  supported  by  the  puboprostatic  ligaments  and  the 
levator  prostatae  (anterior  fibers  of  the  levator  ani). 

It  is  fixed  in  its  relations  to  the  urinary  organs  by  the  urethra, 
which  pierces  it  from  base  to  apex,  as  well  as  by  the  decussation  of  its 
muscular  fibers  with  those  of  the  bladder  and  the  urethra.  It  is  sep- 
arated from  the  pubic  arch  above  and  in  front  and  from  the  rectum 
behind  by  a  loose  fascia,  the  fascia  of  Denonvilliers,  an  offshoot  from 
the  pelvic  fascia  which  passes  down  behind  bladder,  vesicles,  and  pros- 
tate, separating  these  from  the  rectum.  Within  this  fascia  and  sur- 
rounding the  prostate,  especially  in  front,  lies  the  prostatic  plexus 
of  veins. 

Gross  Anatomy. — The  prostate  may  be  considered  as  a  gland  divided 
into  two  parts  by  the  ejaculatory  ducts.  These  enter  the  gland  at  the 
posterolateral  angles  of  its  base,  and  run  through  it  obliquely,  opening 
finally  into  the  iirethra  at  or  near  the  sinus  pocularis.  That  part  of 
the  gland  behind  the  ducts  is  called  the  posterior  lohe.  This  part  of 
the  gland  may  become  carcinomatous.     It  never  becomes  adenomatous. 

The  glandular  tissue  in  front  of  the  ejaculatory  ducts  is  divided 
more  or  less  arbitrarily  into  an  anterior,  a  median  and  two  lateral 
lobes.  Lowsley  ^  has  shown  that  in  fetal  life  these  lobes  are  usually 
quite  distinct.  But  after  birth  the  glands  of  the  anterior  lobe  usually 
disappear  and  the  separation  between  the  other  three,  lying  behind 
and  to  each  side  of  the  urethra,  is  quite  arbitrary.  The  median  lobe 
may  be  inseparable  from  one  or  both  of  its  lateral  fellows.  The  median 
lobe  of  the  normal  prostate  makes  no  projection  from  its  surface.  The 
"middle"  lobe  of  prostatism  is  quite  a  different  matter. 

The  prostate  has  a  thin  fibrous  capsule. 

Microscopic  Anatomy. — The  muscular  tissue  is  arranged  in  so 
irregnilar  a  manner  that  no  two  observers  are  agreed  as  to  its  exact 
distribution.  Walker  ■*  believes  that  the  prostatic  muscle  is  so  arranged 
as  to  compress  the  gland  as  a  whole,  and  each  individual  lobule  of  it 

^Nothnagel's  Specielle  Path.  u.   Therap.,   1899,   xix,   ii,  iii,   4. 
^"'The  Diseases  of  the  Prostate,"  1883,  p.  5. 
^Am.  Jour.  Anai.,  1912,  xiii,  299. 
*  Johns  HopMns  Bull,  1900,  xi,  242. 


PHYSIOLOGY  281 

in  particular,  but  is  not  calculated  to  compress  the  urethra.  This  view 
is  in  accord  with  the  fact  that  women — who  possess  no  prostate — ^have 
complete  control  of  the  bladder  without  anv  additional  muscle  to  take 
the  place  of  this  gland. 

The  internal  or  involuntary  vesical  sphincter  (p.  36)  is  so  inter- 
mingled with  the  muscular  fibers  of  the  prostate  and  urethra  that 
anatomists  differ  as  to  its  proper  relation  to  the  gland. 

The  glands  are  of  the  compound  racemose  type  with  cylindrical  epi- 
thelium, which  may  be  flattened  by  pressure  or  may  appear  in  a  double 
layer.  They  are  collected  into  lobules  (15  to  32  in  number),  each 
lobule  surrounded  by  a  layer  of  muscle  and  emptying  by  a  duct  into 
the  lateral  portions  of  the  floor  of  the  prostatic  urethra,  some  behind  and 
some  in  front  of  the  verumontanum.  All  these  ducts  point  toward  the 
orifices  of  the  ejaculatory  ducts,  so  that  the  prostatic  secretion  is  mingled 
with  the  semen  at  the  moment  of  ejaculation. 

A  small  but  important  group  of  urethral  glands  lies  upon  the  floor 
of  the  urethra  within  the  gTasp  of  the  sphincter.  Occasionally  a  few 
similar  glands  are  found  upon  the  trigone  (glands  of  Albarran). 

The  arteries  are  derived  chiefly  from  the  inferior  vesical.  The  veins 
form  the  prostatic  plexus.  The  lymphatics  are  very  numerous.  They 
pass  to  the  internal  iliac  and  obturator  lymph  nodes.  The  nerves  are 
derived  from  the  inferior  hypogastric  plexus  of  the  sympathetic. 

The  Prostatic  Urethra. — The  urethra  extends  from  the  bladder 
downward  and  forward  through  the  prostate,  so  that,  although  the 
major  part  of  the  gland  lies  below  and  behind  it,  the  urethra  emerges 
quite  at  the  center  of  the  apex  of  the  prostate.  The  anatomy  of  the 
prostatic  urethra  has  already  been  described  (p.  35). 


PHYSIOLOGY 

The  prostate  is  the  sexual  heart.  It  has  nothing  to  do  with  urina- 
tion, and  is  quite  passive  during  this  act.^  But  toward  the  sexual  func- 
tion it  acts  as  a  muscle,  a  sensory  organ,  and  a  gland. 

As  a  muscle  it  acts  to  open  the  ejaculatory  ducts,  thus  permitting 
the  escape  of  the  semen  into  the  prostatic  urethra,  to  express  its  own 
secretion  into  the  prostatic  urethra,  and  probably  to  expel  it  into  the 
anterior  urethra.  The  accepted  function  of  the  verumontanum— viz., 
to  close  the  vesical  orifice  and  prevent  regnrgitation  of  semen  into  the 
bladder — has  been  denied  by  Walker  and  others. 

The  seat  of  sexual  sensation  in  the  prostatic  urethra  is,  perhaps, 

^  For  the  various  aspects  of  this  disputed  question  consult,  besides  the  authors 
already  quoted,  Rehfisch,  Virchow's  Archiv,  1897,  cl,  111;  Finger,  Allg.  If'ien.  med, 
Zeitung,  1893,  xxxviii,  427,  439,  452. 


282  THE  PROSTATE 

throughout  its  mucous  membrane,  but  more  probably  it  is  confined  to 
the  verumontanum.  When  erection  has  been  stimulated  by  friction  of 
the  glans  penis  the  verumontanum  becomes  congested  and  irritated, 
perhaps  by  a  spinal  reflex,  perhaps  by  the  gradual  influx  of  semen  into 
the  prostatic  urethra,  and  ejaculation  results. 

The  glandular  function  of  the  prostate  is  no  less  interesting.  Be- 
sides acting  as  a  simple  diluent,  it  adds  something  to  the  semen  that 
keeps  the  spermatozoa  alive  for  several  days,  whereas  other  diluting 
fluids  keep  them  alive  only  three  or  four  hours. 

The  secretion  of  the  prostate  is  a  thin,  turbid  fluid  of  v^atery  con- 
sistence, of  slightly  acid  reaction,  and  of  seminal  odor.  Its  qualities  in 
health  and  disease  have  already  been  described  (p.  164). 

There  is  probably  an  internal  prostatic  secretion  that  stimulates 
spermatogenesis. 

PROSTATISM 

Prostatism,  miscalled  prostatic  hypertrophy,  is  an  adenomatous 
or  sclerotic  condition  of  the  prostate,  causing  obstruction  to  the  out- 
flov^  of  urine  through  the  urethra. 

Although  every  adenomatous  prostate  shoves  areas  of  sclerosis  and 
every  sclerotic  prostate  adenoma,  it  is  convenient  to  distingTiish  the 
common  or  adenomatous  type  of  prostatism  from  the  rare  sclerotic 
type. 

ETIOLOGY 

Age. — Prostatism  is  a  disease  of  later  life.  It  rarely  causes  symp- 
toms before  the  fiftieth  year.  Although  individual  cases  have  been 
reported  at  the  ages  of  nineteen  (Stretton),  twenty-five  (Englisch), 
thirty-seven  (Thompson),  etc.,  these  are  altogether  exceptional.  The 
pathologic  changes  begin  early  in  life,^  yet  there  is  no  clinical  evidence 
of  any  such  change  until  many  years  later.  The  patients  begin  to 
suffer,  for  the  most  part,  between  the  ages  of  fifty  and  sixty-five. 

Frequency. — According  to  Thompson's  figures,  34  per  cent  of  men 
reaching  the  age  of  sixty  have  enlarged  prostates,  and  less  than  half  of 
these  (15  to  16  per  cent  of  the  whole)  suffer  from  prostatism.  This 
estimate  is  substantially  accurate. 

The  size  of  the  hypertrophy  bears  no  relation  to  the  age  of  the  pa- 
tient, nor,  as  we  shall  see,  to  the  symptoms. 

Pathogenesis — Though   no   satisfactory   theory   has   yet   been   ad- 

^  Gardner  and  Simpson  {Trans.  Am.  Urol.  Ass7i.,  1913)  found  only  one  adenoma 
among  15  prostrates  of  men  less  than  40  years  of  age.  They  found  five  adenomata 
among  19  prostates  of  men  between  40  and  50  and  seven  among  21  in  the  next 
decade. 


PROSTATISM  283 

vanced  to  account  for  prostatism,  many  ingenious  suppositions  have  had 
ardent  defenders,  and  so  require  at  least  a  brief  notice. 

1.  Aeterioscleeosis  (Guyon,^  Launois  ^). — The  lesion  of  the  pros- 
tate is  supposed  to  be  only  part  of  a  series  of  senile  changes  affecting 
the  whole  urinary  tract  and  associated  with  general  arteriosclerosis. 

Casper  ^  and  Motz  *  overthrow  this  theory  by  showing  that  sclerosis 
could  exist  without  prostatism,  and  prostatism  without  sclerosis.  The 
association  of  the  two  appears  to  be  purely  fortuitous. 

2.  Fibromyoma  (Velpeau^). — Velpeau  suggested  that  there  exists 
a  biological  analogy  between  the  prostate  and  the  uterus,  and  a  histo- 
logical analogy  between  fibromyoma  of  the  uterus  and  prostatism. 
Thompson  '^  amplified  and  defended  the  theory,  and  it  has  received  ad- 
ditional weight  by  the  alleged  effects  of  castration  upon  uterine  myoma 
and  prostatism. 

This  theory  has  been  exploded  by  the  recognition  of  the  fact  that 
the  prostate  is  analogous  to  the  uterus  neither  in  development,  in 
structure,  nor  in  function,  and  that  prostatism  is  not  fibromyomatous, 
but  adenofibromatous. 

3.  Sexual  Senility  (White '^). — "The  function  of  the  testis,  like 
that  of  the  ovary,  is  twofold — the  reproduction  of  the  species  and  the 
development  and  preservation  of  the  secondary  sexual  characteristics  of 
the  individual.  The  need  for  the  exercise  of  the  latter  function  ceases 
when  full  adult  life  is  reached,  but  it  is  possible  that  the  activity  of  the 
testis  and  that  of  the  ovary  in  this  respect  do  not  disappear  coincidently, 
and  that  hypertrophies  in  closely  allied  organs  like  the  prostate  and 
uterus  are  the  result  of  this  misdirected  energy."  The  facts  adduced 
by  White  cannot  be  denied ;  but  his  theory,  based  upon  the  false  pro- 
stato-uterine  analogy  and  the  implied  power  of  the  testicle  to  cause 
prostatism  .and  devised  to  defend  the  cause  of  castration  as  a  remedy 
for  prostatism,  is  an  assumption  not  borne  out  by  the  facts. 

4.  Congestion. — A  chronic  congestion  of  the  gland  has  been  consid- 
ered by  many  the  chief  predisposing  cause  of  prostatism.  Many  varie- 
ties of  congestion  have  been  insisted  upon.  Some  authors  incriminate 
a  pelvic  congestion,  such  as  is  caused  by  gormandizing  and  a  sedentary 
life,  and  expressed  by  hemorrhoids.  Others  insist  upon  chronic  ure- 
thritis or  sexual  excess ;  and  a  few  would  even  blame  a  too  strict  conti- 
nence. 

Young  has  noted  that  most  of  his  patients  were  married  men. 

^  Guyon's  Annales,  1885,  iii,  148. 

^ ' '  De  1  'appareil  urinaire  des  vieillards, ' '  Paris,  1885. 

^Virchow's  ArcJiiv,  1891,  cxxvi,  139. 

*" Structure  histologique  de  I'hypertrophie  de  la  prostate,"  Paris,  1896. 

""Legons  orales,"  Paris,  1841,  iii,  478. 

•"On  the  Diseases  of  the  Prostate."    Fourth  edition,  1873,  p.  53. 

''Annals  of  Surgery,  1893,  xviii,  152, 


284  THE  PROSTATE 

5.  Inflammation.  —  Ciecllaiiowski  ^  alleges  tliat  prostatism, 
whether  adenomatous  or  sclerotic,  is  essentially  the  same;  that  it  is 
due  to  obscure,  inflammatory  processes  originating  in  the  stroma  of  the 
gland;  and  that  the  so-called  adenomata  and  fibromata  are  secondary 
changes  due  to  the  dilatation  of  gland  ducts  and  acini  whose  mouths  are 
obstructed. 

Liechanowski  further  notes  the  fact  that  the  underlying  stroma 
changes  found  by  him  in  the  prostates  of  old  men  are  the  same  as 
those  found  by  Casper  in  the  prostates  of  young  men  who  had  suffered 
from  gonorrheal  prostatitis.  Hence  the  corollary  that  perhaps  the 
prostatism  of  old  age  is  due  to  the  gonorrhea  of  youth.  This  sugges- 
tion, tentatively  set  forth  by  Ciechanowski,  has  been  seized  upon  by 
several  writers  as  an  unavoidable  inference,  and  is  by  them  flaunted  to 
the  gTeat  shame  of  the  large  and  respectable  army  of  prostatics. 

In  order  to  test  this  theory  from  the  clinical  side,  I  have  collected  ^ 
the  histories  of  a  great  number  of  men  who  have  reached  the  age  of 
fifty  after  having  suffered  prolonged  attacks  of  chronic  gonorrhea,  and 
cannot  find  that  they  show  any  special  tendency  to  suffer  from  prosta- 
tism. This,  taken  in  connection  with  the  fact  that  every  established 
genito-urinary  practitioner  can  call  to  mind  many  prostatics  who — he 
may  be  morally  certain — ^never  had  gonorrhea,  seems  to  establish  the 
fact  that  the  prostatic  sclerosis  is  not  necessarily  gonorrheal,  but  may 
be  due  to  the  congestion  of  sexual  excess  or  of  continence,  to  gonorrhea, 
or  simply  to  advancing  years.  Where  chiefly  to  lay  the  blame  we  do  not 
know ;  in  the  meanwhile  let  charity  temper  our  provisional  conclusions. 

6.  ISTegplasm. — The  consensus  of  pathologic  opinion  attributes  the 
adenomatous  changes  to  a  true  neoplastic  process,  the  sclerotic  changes 
to  inflammation.  We  may,  for  the  present,  accept  this  theory,  while 
awaiting  decisive  proof  one  way  or  the  other. 

It  seems  probable  that  whatever  conclusion  is  reached  in  this  obscure 
matter  will  be  based  upon  the  fact  that  the  prostate  tends  to  undergo 
retrograde  changes  with  cessation  of  its  sexual  function,  as  do  the  uterus 
and  the  female  breast.  How  far  prostatism  will  be  found  attributable 
to  this  normal  involution,  and  how  far  to  neoplasm,  to  the  inflamma- 
tions of  youth,  and  to  the  congestion  of  sexual  excess,  the  future  must 
determine. 

MORBID  ANATOMY 

Microscopic  Changes. — ^We  may  distinguish  a  diffuse,  hard,  fibrous 
type,  and  a  type  characterized  by  the  growth  of  encapsulated  adenomata. 

^"So-called  Prostatic  Hypertrophy,"  translation  edited  by  Dr.  E.  H.  Greene, 
1903.  Cf.  also  Rothschild,  Berl.  Min.  Wochenschr.,  1909,  xlvi,  No.  27.  Also  Wilson 
and  MeGrath,  Jour.  Am.  Med.  Assn.,  1911,  Ivii,  1601. 

''■Jour.  Am.  Med.  Assn.,  1904,  XLTII,  187. 


PROSTATISM 


285 


\ 


Fig.  53. — Adenoma  Enucleated 

FROM         A          HyPERTKOPHIED 

Prostate. 


'No  given  example  adheres  strictly  to  either  type ;  indeed,  it  is  the  rule 
to  find  each  existing  in  different  parts  of  the  specimen:  in  one  place 
a  dense  mass  of  tibrous  tissue,  and  scattered  everywhere  enucleable 
tumors,  large  and  small,  the  larger  ones 
(Figs.  53,  54)  complex  in  structure. 

It  is  to  be  noted  that  the  fibrous  changes 
do  not  result  in  any  actual  enlargement  of 
the  gland.  This  enlargement,  whence  the 
name  ''prostatic  hypertrophy,"  is  due  to  the 
adenomatous  change,  diffuse  or  circum- 
scribed. This  adenomatous  change  takes 
place  in  that  part  of  the  gland  nearest  the 
urethra, -"^  whether  laterally  or  below,  and  by 
its  growth  compresses  the  outer  portions  of 
the  gland  tissue  to  such  an  extent  that  these 
form  a  firm  pseudocapsule  from  within 
which  the  adenomatous  masses  may  usually 
be  readily  enucleated. 

Exceptionally  the  fibrosis  so  predominates  that  enucleation  is  im^ 
possible,  the  diseased  portions  of  the  gland  being  so  welded  to  its  periph- 
ery by  scar  tissue  that  the  whole  organ  forms  one  sclerotic  mass.  Such 
prostates  usually  show  an  actual  contraction  of  the  prostatic  urethra 

and  bladder  neck. 

It  is  to  be  further  noted, 
therefore,  that  enucleation  of 
the  enlarged  prostate  leaves 
behind  the  peripheral  por- 
tions of  the  gland. 

Macroscopic  Changes. — 
1.  The  posterior  lobe,  behind 
the  ejaculatory  ducts,  is  not 
concerned  in  prostatism. 

2.  The  "capsule"  consists 
of  this  lobe  plus  the  com- 
pressed peripheral  portions 
of  the  other  lobes. 

3.  When  adenomatous 
changes  predominate,  as  they 
do  in  90  per  cent  of  cases,  the 

adenomata  are  usually  found  generally  distributed  in  the  form  of  two 
lateral  and  one  middle  lobe. 


Fig.  54. — Section  of  a  Large  Prostatic  Adeno- 
ma,   Showing   It.s   Composite   Character. 


^  Whether  in  tlie  prostate  itself  or  in  the  periurethral  glands  is  not  agreed  (Cf. 
Gardner  and  Simpson,  I.  c;  also  Motz,  Bev.  din.  d'Urol.,  Jan.,  1914).    . 


286  THE  PROSTATE 

4.  Exceptionally  the  gross  diange  is  confined  to  one  lobe,  usually 
the  middle. 

5.  These  adenomatous  cases  show  a  dilated  urethra. 

6.  The  sclerotic  cases,  on  the  other  hand,  are  due  to  a  general 
sclerosis,  producing  a  rigid  tight  ring  at  the  bladder  neck  (contracture), 
and  often  a  constriction  of  the  whole  prostatic  urethra. 

Desnos's  ^  specimens  ranged  in  weight  from  23  to  85  grams.     Much 


Fig.  55. — Pkostatism  ;  Transverse  Section  Showing  Enlargement  of  Lateral  Lobes. 
3,  Lateral  Lobe;  5,  Urethra;  6,  6,  Capsule;  8,  Verumontanum. 

larger  tumors  are  occasionally  met  with,  but  in  the  usual  run  of  cases 
the  prostate  is  much  smaller  than  a  mandarin  orange. 

The  most  notable  gross  changes  associated  with  prostatism  are  (1) 
bulging  of  the  posterior  surface  of  the  gland,  (2)  elevation  of  the  ure- 
thral orifice,  (3)  production  of  a  projecting  middle  lobe,  and  (4) 
lengthening  and  distortion  of  the  prostatic  urethra. 

1.  Posterior  Enlargement. — In  a  large  proportion  of  cases  the 
lateral  lobes  of  the  prostate  are  enlarged.  Such  an  enlargement  may 
be  felt  by  rectal  touch.  The  examining  finger,  instead  of  impinging 
upon  a  scarcely  perceptible  organ,  encounters  a  large  mass,  perhaps  the 

^Desnos,  "Maladies  des  voies  urinaires,"  1898,  p.  386. 


PLATE    X 


The  Usual  Type  of  Prostatism. 


General  prostatic  enlargement,  with  middle  lobe  projection.     Note  position  of  verumon- 

tanum. 


Fig.  56. — Bilateral  Prostatic  Enlargement.  Fig-  57. — General  Sclerosis  of  the  Prostate,     The 

Contracture  Type. 


58.— General  Enlargement  OF  TiiK  Prostate  with        Fig.  59. — Pedunculatku    Mloian  Enlargement. 
Median  Bar. 


287 


288 


THE  PROSTATE 


size  of  a  plum,   perhaps  so   large  that  its   upper  border   cannot   be 
reached.     To  estimate  the  size  of  the  growth  the  finger  is  swept  over 


Fig.  60. — Sagittal  Section  op  Fig.  66. 


Fig.  61. — Sagittal  Section  of  Fig.  57. 


it  from  side  to  side,  into  the  sulci  between  it  and  the  lateral  wall  of 
the  rectum,  and,  if  possible,  over  the  top  of  the  tumor.  Its  increase  in 
all  three  dimensions  may  thus  be  fairly  estimated  and  its  general  elas- 


FiG.  62. — Sagittal  Section  op  Fig.  58. 


Fig.  63. — Sagittal  Section  op  Fig.  59. 


ticity  determined.     In  shape  the  mass  is  usually  quite  globular,  but 
a  little  furrowed  down  the  center.      One  lobe  may  be  more  hyper- 


PROSTATISM 


289 


trophied  than  the  other.     Small  phleboliths  may  be  felt  upon  the  gland. 

2.  Elevation  of  the  Urethral  Orifice. — When  bladder  and 
prostate  are  normal,  the  urethral  orifice  practically  lies  on  the  same 
level  as  the  trigone  and  the  floor  of  the  bladder.  But  every  form  of 
prostatism  disturbs  this  relation.  If  the  growth  is  purely  lateral, 
whether  on  one  or 
both  sides,  the  tumor 
lifts  a  fold  of  mu- 
cous membrane  at 
the  urethral  orifice 
(Fig.  56).  If  there 
is  general  enlarge- 
ment, the  prostate 
projects  upward  into 
the  bladder,  pushing 
the  urethra  before  it 
and  forming  the  so- 
called  har  at  the  neck 
of  the  bladder  (Figs. 
58,  62).  The  mid- 
dle   lobe    (Fio-.    59) 

'^*  Fig.  64. — Section  of  Enlarged  Prostate.     Compare  ure- 

acts  m  the  same  way.  thral  curves  in  Figs.  64  and  65. 

Finally,    the   fibrotic 

type  (Fig.  57)  of  prostatism  causes  a  true  contracture  of  the  nech  of  the 

bladder,  with  increased  elevation  of  the  urethral  orifice.^ 

3.  The  Middle  Lobe. — This  term  is  loosely  used  to  indicate  any 
projection  into  the  bladder,  be  it  bar  or  tumor.  Properly  speaking,  the 
middle  lobe  of  the  prostate  is  a  distinct  outgrowth  from  the  neck  of 
the  bladder  or  from  the  floor  of  the  prostatic  urethra  (Fig.  59).  This 
tumor  springs  from  the  posterior  commissure  of  the  gland,  and  was 
supposed  to  originate  within  it.  But  Jores  -  showed  that  ^4ts  first 
beginning  occurs  in  the  accessory  prostatic  glands  which  lie  just  under 
the  mucous  membrane,  and  the  projection  into  the  bladder  is  due  at  first 
to  the  hypertrophy  of  these  alone."  These  outlying  glands  are  usually 
situated  at  the  urethral  orifice  "directly  beneath  the  mucous  membrane 
and  between  the  circular  fibers  of  the  bladder  and  the  middle  isthmus  of 
the  prostate"   (Alexander^).     The  middle  lobe  is  rarely  more  than  2 

*Eochet  ("Traite  de  la  dysurie  senile,"  Paris,  1899)  gives  some  space  to  fhe 
consideration  of  those  unusual  forms  of  hypertrophy  in  which  the  upper  lobe  is 
chiefly  affected,  and  there  is  no  elevation  of  the  urethral  orifice.  Such  a  case  was 
also  illustrated  in  a  previous  edition  of  this  treatise. 

"Virchoiv's  -Archiv,  1894,  CXXTX,  224. 

^  Med.  Record,  1899,  LVI,  982. 
The  observation  of  Tandler  and  Zuckcrkandl   (Folia  Urolngica,  1911,  p.   1117) 
and  of   Motz    (Marion,   Trans.  French    Urolog.   Jasn.,   1911),   tend   to '  attribute   all 


290 


THE  PROSTATE 


cm.  in  diameter.     It  will  be  observed  that  some  median  enlargement  is 
noted  in  81  per  cent  of  the  tabulated  cases. 

4.  Lengthening  and  Distortion  of  the  Pkostatic  Urethra. — 
The  prostatic  urethra  is  altered  in  length,  size, and  curve  (Figs.  60  to  65). 
The  urethra  is  always  lengthened  by  the  increased  size  of  the  prostate. 
But  the  lengthening  of  the  canal  occurs  between  the  verumontanum  and 
the  bladder  neck  and  is  more  on  the  floor  than  on  the  roof  (PL  X). 
The  urethra  is  dilated  chiefly  by  the  growth  of  the  lateral  lobes 

which  enlarge  on  each  side 
of  it  and  spread  it  out  on  a 
vertical  plane,  so  that,  from 
being  a  transverse  slit,  it  is 
altered  to  a  vertical  one,  with 
perhaps  a  curve  to  one  side 
or  the  other,  where  a  projec- 
tion in  one  lobe  fits  into  a 
depression  in  its  fellow  of 
the  opposite  side.  The  dila- 
tation may  be  so  great  that 
an  ordinary  sound  can  be  ro- 
tated quite  freely  within  the 
canal,  thus  giving  the  false 
impression  that  the  bladder 
has  been  reached.  The 
urethra  is  contracted  in  pure- 
ly sclerotic  cases.  The  curve 
of  the  urethra  is  lengthened. 
That  is,  its  internal  orifice  is  carried  upward  and  backward,  and  the 
canal,  instead  of  having  the  short  normal  curve,  sweeps  in  a  curve  of 
much  longer  radius,  a  curve  that  requires  special  "natural"  catheters 
with  the  long  curve  (Fig.  64).  The  urethra  is  further  deformed  by 
the  presence  of  the  bar,  below  which  the  canal  forms  a  distinct  pouch, 
or  by  the  projection  into  it  of  tumors  from  the  various  lobes,  notably 
the  middle  lobe. 


Fig.   65. — Section   of   Normal   Prostate. 


PATHOLOGICAL  PHYSIOLOGY  AND  SECONDARY  MORBID  CHANGES 

Retention,  Congestion,  Inflammation — these  are  the  Fates  of  the 
prostatic. 

Retention. — The  causes  of  retention  of  urine  are  to  be  found  both 
in  the  prostate  and  in  the  bladder.  The  prostate  is  primarily  at  fault, 
I  do  not  remember  to  have  seen  retention  of  urine,  whether  complete  or 

prostatic   adenomata,   whether   "middle"   or   "lateral,"   to   glands  adjacent   to   the 
urethra.     We  may  reserve  judgment  until  the  dispute  is  settled. 


PROSTATISM  291 

incomplete,  in  any  prostatic  who  had  not  some  obstruction  at  the  neck 
of  his  bladder,  some  elevation  of  the  urethral  orifice  (whether  such  ele- 
vation was  absolute  or  merely  relative  to  the  bladder),  by  bar,  middle 
lobe,  or  contracture  of  the  neck  of  the  bladder.  These  changes  about 
the  urethral  orifice  disturb  its  physiological  relation  to  the  bladder. 
When  in  the  act  of  urination  the  bladder  contracts,  it  forces  the  urine 
over  the  prostatic  bar  with  gTeat  difficulty ;  it  is  overstrained.  To  esti- 
mate the  efi'ects  of  this  strain,  the  condition  of  the  bladder  at  this  time 
of  life  must  be  borne  in  mind.  In  the  child  the  organ  is  ovoidal  with 
the  sharper  end  at  its  neck ;  it  has  no  fioor.  But  as  adult  life  is  reached 
it  settles  down  into  the  pelvis.  Its  trigone  becomes  more  and  more 
horizontal.  It  acquires  a  floor.  As  age  advances  it  tends  to  sag  more 
and  more.  In  the  female  it  bulges  down  until  it  forms  a  cystocele. 
But  in  the  male  the  bladder  neck  is  supported  by  the  urethral  and  pros- 
tatic attachments  to  the  pubes,  and,  as  the  bladder  sags,  it  thus  tends  to 
pouch  behind  the  prostate,  the  trigone  swings  around  until  it  forms  the 
anterior  incline  of  this  pouch — the  has  fond,  as  the  French  call  it. 
While  there  may  be  some  has  fond  without  prostatism,  without  obstruc- 
tion of  the  urethra,  such  a  has  fond  has  no  clinical  significance.  But 
when  there  is  urethral  obstruction  and  heightened  vesical  tension  at  a 
time  of  life  when  the  muscles  are  becoming  fibrotic  and  losing  their 
energy,  the  result  is  a  relatively  rapid  pouching  of  the  floor  of  the 
bladder,  a  general  weakening  of  its  muscle,  and  an  inability  of  the  organ 
to  empty  itself  completely.  Thfe  has  fond  is  never  dry ;  there  is  always 
some  urine  left  in  the  bladder;  in  short,  there  is  partial  retention  of 
urine.  It  is  as  though  the  bladder  were  a  tank  with  the  outlet  upon 
one  side  instead  of  at  the  bottom.  '» However  often  the  water  is  allowed 
to  drain  off  from  the  tank  none  of  its  contents  below  the  level  of  the 
outlet  pipe  can  escape  and  the  tank  cannot  be  completely  emptied. 

As  a  result  of  this  vesical  derangement,  and  because  of  the  low  vital- 
ity of  its  dilated  and  inflamed  parenchyma,  the  prostate,  perhaps  still 
bearing  the  scars  of  ancient  battles  with  the  gonococcus,  is  very  subject 
to  attacks  of  acute  congestion.  A  Christmas  dinner,  an  exposure  to 
cold,  particularly  of  the  legs,  a  slight  alcoholic  excess,  may  bring  on 
acute  congestion  in  a  prostate  that  has  given  no  previous  trouble.  The 
patient  may  have  had  a  little  retention  of  urine  quite  unconsciously, 
until  some  day  his  acute  congestion  comes  and  he  cannot  pass  water. 
Perhaps  he  succeeds  in  relieving  himself  by  dint  of  hot  baths  and  strain-  (^^ 
ing;  perhaps  his  urine  has  to  be  drawn  from  him.  The  attack  may  be 
lasting,  or  transitory,  it  may  or  may  not  terminate  in  inflammation;  in 
any  case,  it  causes  a  temporary  complete  retention  of  urine,  increases  the 
chronic  partial  retention,  and  enhances  the  efi^ects  of  this  retention  upon 
the  upper  urinary  organs.  And  the  constant  pressure  of  the  retained 
urine  produces  in  turn  a  chronic  congestion  of  the  prostate. 


292  THE  PROSTATE 

The  Bladder. — As  a  result  of  this  retention  of  urine,  the  bladder 
not  only  changes  its  general  shape  but  also  becomes  trabeculated,  and 
even  sacculated;  while  the  cystitis  causes  a  gradual  sclerosis  of  the 
bladder  wall,  and  even  a  pericystitis.  As  a  final  result,  the  bladder  is 
left  in  that  condition  of  atony  described  on  page  367 ;  though,  if  inflam- 
mation predominates  over  retention  in  the  earlier  stages  of  the  disease, 
the  interstitial  cystitis  may  result  in  pseudohypertrophy.  Stone  in  the 
bladder  is  a  frequent  result  of  prostatism. 

The  Uketers  and  Kidneys. — Dilatation,  infection  and  stone  effect 
the  ureters  and  kidneys,  as  well  as  the  bladder.  With  this  difference, 
however,  that  the  renal  destruction,  though  the  usual  cause  of  the 
patient's  death,  progresses  so  silently  that  the  victim  does  not  suspect 
its  existence. 


CHAPTER    XXX 

THE  SYMPTOMS,  DIAGNOSIS  AND  PROGNOSIS  OF  PROSTATISM 

SYMPTOMS 

Inasmuch  as  prostatism  causes  no  noteworthy  symptoms  until  it 
produces  retention  of  urine,  the  pathological  changes  in  the  prostate 
exist  for  years  before  the  onset  of  symptoms ;  and  the  prostate  may  be 
much  enlarged  without  provoking  symptoms,  so  long  as  it  does  not 
cause  retention.  Thus,  I  have  seen  a  man  of  80  years  of  age,  with  a 
prostate  four  times  its  normal  size^  whose  attention  had  been  only  re- 
cently called  to  his  urinary  organs  by  the  symptoms  arising  from  a 
secondary  stone  in  the  bladder.  The  presence  of  prostatism  does  not 
imply  the  existence  of  symptoms.  Furthermore,  the  small  sclerotic 
prostate  may  cause  all  of  the  symptoms  that  arise  from  the  large  adeno- 
matous prostate.  Indeed,  the  sclerotic  prostate  is  likely  to  cause 
trouble  earlier  in  life  (much  more  difficult  to  relieve  by  operation)  than 
its  more  familiar  adenomatous  fellow. 

The  symptoms  of  prostatism  are : 

1.  Symptoms  of  retention,  viz.:  Frequent  urination;  urinary 
toxemia. 

2.  Symptoms  of  infection,  viz. :  Infection  of  the  upper  urinary 
tract;  urinary  septicemia;  pyonephrosis;  prostatic  abscess;  vesiculitis; 
epididymitis. 

3.  Hemorrhage. 

4.  Sexual  symptoms. 

Symptoms  of  Retention — I^octurnal  Frequency  of  Urination. 
- — This  is  almost  invariably  the  first  symptom  of  prostatism.  Even 
before  there  is  any  infection  or  any  notable  retention  of  urine  in  the 
bladder  the  patient  has  to  arise  several  times  at  night  to  urinate.  This 
irritation  is  usually  most  marked  after  4  a.  m.,  and,  doubtless,  is  asso- 
ciated with  that  pelvic  congestion  which'  excites  erections  in  younger 
men. 

Painful  and  Difficult  TJri nation. — During  these  hours  of  maxi- 
mum frequency  of  urination,  the  patient  recognizes  an  obstruction  to 
the  flow.  He -has  to  wait  a  long  time  for  it  to  start,  it  comes  in  a  feeble 
stream,  and  is  slow  to  stop.  The  more  he  strains  the  less  he  is  able  to 
urinate,  and  he  can  often  only  empty  his  bladder  by  repetitious  efforts. 

293 


294  PROSTATISM 

As  the  amount  of  residual  urine  increases,  or  infection  supervenes, 
urination  becomes  painful  as  well  as  difficult ;  frequent  by  day  as  well  as 
by  nigbt. 

Acute  Retention  of  Urine.— As  a  result  of  overeating  or  drink- 
ing, exposure  to  cold  and  wet  or,  above  all,  voluntary  retention  of  urine 
against  the  call  of  nature,  the  prostate  may  become  suddenly  so  con- 
gested as  to  excite  spasm  in  the  sphincter  and  acute  complete  retention 
of  urine.  This  may  be  rdftev&d  spontaneously,  or  by  a  hot  bath,  but 
usually  requires  the  catheter.  If  neglected,  it  may  kill  the  patient, 
or  leave  him  in  a  condition  of  overflow. 

OvEKFLOw. — True  incontinence  of  urine,  i.e.,  the  involuntary  loss 
of  urine  without  filling  of  the  bladder,  does  not  occur  as  the  result  of 
prostatism.  The  loss  of  urine  that  does  occur  is  o^^erflow  from  the 
chronically  overdistended  bladder.  This  overflow  is  usually  associated 
with  irritation  of  the  bladder,  so  that  the  patient  urinates  whether  he 
will  or  no  at  least  once  an  hour,  perhaps  oftener,  and  between  urinations, 
especially  during  the  night,  he  loses  urine  involuntarily. 

Symptoms  of  Changes  in  the  Upper  Urinary  Organs. — As  a  result 
of  infection  and  dilatation  of  the  bladder  and  the  kidneys,  the  patient 
suffers  from  urinary  toxemia,  or  urinary  septicemia.  His  frequency 
of  urination  is  increased  by  cystitis  and  stone  in  the  bladder,  and  by 
the  polyuria  of  renal  dilatation. 

Fever  m.ay  be  due  to  infection  in,  the  prostate,  in  the  kidneys  (pyo- 
nephrosis), or  in  the  epididymes. 

Hemorrhage. — Bleeding  is  much  more  common  from  prostatism 
than  from  prostatic  carcinoma.  The  bleeding  is  due  either  to  an  ulcera- 
tion on  the  surface  of  the  prostate  itself,  or  to  secondary  stone  in  the 
bladder.  It  may  be  of  that  profuse  quality  so  suggestive  of  malignant 
neoplasm;  it  may  occur  quite  independently  of  the  passage  of 
instruments. 

Sexual  Symptoms — The  combination  of  ag©  and  disease  usually 
diminishes  or  obliterates  sexual  power  and  desire.  Exceptionally,  how- 
ever, the  congested  prostate  excites  abnormal  erections  which  may  drive 
the  patient  into  neurasthenia,  or  into  all  sorts  of  sexual  excesses. 


ONSET  OF  THE  DISEASE 

While  the  first  symptom  of  the  prostatism  for  which  the  patient 
consults  a  physician  may  be  hemorrhage,  a  prostatic  abscess,  some 
sexual  disturbance,  or  some  other  relatively  unusual  manifestation, 
the  symptoms  usually  l)egin  in  one  of  three  ways. 

The  Usual  Type — The  symptoms  begin  with  nocturnal  frequency 
and  difficulty  of  urination.     This  increases  gradually  and  the  patient 


COURSE  OF  THE  DISEASE  295 

passes  on  througli  the  first,  second  and  third  stages  of  the  disease  as 
described  below. 

The  Acute  Complete  Retention  Type. — Acute  complete  retention  of 
urine  may  supervene  at  any  moment  in  the  course  of  the  disease.  It  is 
the  first  symptom  of  importance  in  almost  half  the  cases. 

If  promptly  treated  it  may  sometimes  be  relieved,  and  the  bladder 
resume  its  ability  to  empty  itself  satisfactorily.  But  if  the  infection 
cannot  be  controlled,  or  if  after  relief  of  the  acute  complete  retention 
some  residual  urine  remains,  the  acute  complete  retention  will  soon 
recur.  Very  few  patients  with  acute  complete  retention  escape  further 
trouble  within  the  year.  Yet  they  may  escape  for  a  number  of  years 
without  any  further  symptoms. 

Urinary  Toxemia. — The  patient  with  a  tolerant  uninfected  bladder 
ma}^  never  have  an  acute  complete  retention  of  urine  and  may  not  con- 
cern himself  about  his  gradually  increasing  frequency  of  urination.  He 
may- thus  reach  a  condition  of  chronic  distention  of  bladder  and  kidneys 
without  consulting  a  physician.  Under  such  circumstances  the  first 
condition  that  he  notes  is  a  loss  of  weight  and  strength,  accompanied  hy 
constipation  and  dry  mouth.  Even  these  he  may  not  note  until  a  slight 
infection  adds  fever  to  his  symptoms.  Such  patients,  unless  carefully 
examined,  may  be  treated  for  digestive  disturbances  for  a  considerable 
time ;  though  the  mere  laying  of  a  hand  upon  the  lower  belly  identifies 
the  distended  bladder  and  intelligent  investigation  of  the  patient's  his-  / 
tory  will  reveal  polyuria,  frequency  of  urination  and  dry  mouth.       1/ 


COURSE  OF  THE  DISEASE 

The  course  of  the  disease  is  divided  into  three  periods :  The  period 
of  congestion ;  the  period  of  partial  retention ;  the  period  of  complete 
retention.  The  two  former  may  be  introduced  or  interrupted  by  attacks 
of  acute  complete  retention.     Hemorrhage  may  occur  at  any  time. 

1.  Congestion — During  this  period  there  is  little  or  no  retention  of 
urine,,  but  only  a  slight  nocturnal  irritability  of  the  bladder  with  often 
nocturnal  polyuria  and  perhaps  attacks  of  prostatitis  or  of  sexual 
irritability  amounting  almost  to  priapism. 

As  a  rule  the  symptoms  are  slight  during  this  period  unless  there  is 
acute  complete  retention.  But  either  on  account  of  nocturnal  polyuria, 
stone  or  prostatic  irritability  there  may  be  great  frequency  by  night  and 
sometimes  also  by  day ;  although  the  amount  of  urine  retained  does  not 
exceed  25  to  50  c.c. 

2.  Partial  Retention — The  passage  from  congestion  to  partial  re- 
tention, unless  marked  by  an  acute  retention,  is  quite  insensible.  Re- 
sidual urine  begins  to  accumulate  in  the  bladder,  as  a  result  not  of  an 


296  PROSTATISM 

enlargement  of  the  prostate,  but  of  weakening  of  the  bladder  muscle. 
The  patient  merely  notes  an  added  frequency  of  urination  or,  if  infec- 
tion occurs,  a  clouding  or  stinking  of  his  urine,  while  the  difficulty  and 
pain  in  the  urinary  act  increase  and  become  diurnal  as  well  as  noc- 
turnal. The  limit  of  incomplete  retention,  both  as  to  time  and  quan- 
tity, are  quite  indefinite.  The  patient  who  retains  a  pint  of  urine  and 
yet  has  to  pass  water  only  every  three  or  four  hours  and  empties  out 
six  or  eight  ounces  of  urine  each  time  cannot,  strictly  speaking,  be 
said  to  be  in  a  state  of  chronic  complete  retention.  As  a  rule,  how- 
ever, by  the  time  the  patient's  retention  amounts  to  250  c.c,  his  urinary 
calls  are  so  frequent  and  the  amount  he  passes  so  small  that  his  bladder 
may  be  said  to  be  full  all  the  time.  He  is  in  the  third  stage  of  the 
disease. 

3.  Complete  Retention. — With  the  occurrence  of  chronic  complete 
retention,  the  bladder  is  practically  full  all  the  time.  If  contracted  or 
badly  inflamed  this  fullness  may  be  reached  with  only  50  or  100  c.c. 
of  urine.  If  dilated  and  uninflamed,  500  c.c.  may  be  the  measure  of 
capacity.  But  the  condition  of  chronic  complete  retention  means  fre- 
quent urination  (every  hour  or  less)  the  passage  of  small  quantities 
(about  50  c.c.)  and  is  always  associated  with  dilatation  of,  and  usually 
with  infection  of,  the  ureters  and  kidney  pelves.  If  neglected  the  pa- 
tient is  unable  to  control  his  urination  and  is  more  or  less  constantly  wet 
as  the  result  of  his  involuntary  overflow. 

The  back  pressure  has  now  made  itself  felt,  the  bladder  is  either 
dilated  or  contracted,  but  in  either  case  the  ureters  and  the  kidney  pelves 
are  dilated,  the  renal  parenchjTna  thin,  the  kidneys  in  a  state  of  chronic 
congestion  either  infected  or  ready  to  flare  up  into  acute  inflammation 
with  the  first  passage  of  a  catheter. 

The  patient  now,  however  careless,  can  neglect  treatment  no  longer. 
The  future  course  of  his  disease  depends  upon  the  treatment  he  receives. 

VARIATIONS  IN  THE   COURSE   OF   THE  DISEASE 

While  the  above  description  applies  to  many  cases,  the  progress 
from  one  stage  to  the  next  may  not  be  so  systematic.  Appropriate 
treatment  may  carry  the  patient  back  from  the  stage  of  partial  reten- 
tion to  that  of  mere  congestion,  or  from  complete  back  to  partial  reten- 
tion ;  or  an  isolated  acute  retention  may  be  relieved  and  be  followed  by 
a  long  interval,  even  an  interval  of  several  years,  during  which  the 
patient  suffers  not  at  all,  and  there  is  no  retention  whatever. 

The  inflammatory  complications  are,  however,  the  chief  agencies  in 
modifying  the  course  of  the  disease.  These  complications  occur  sooner 
or  later  in  every  case,  and  once  the  inflammation  has  set  in  it  is  almost 
impossible  to  get  rid  of  it.    The  inflammation  is  usually  due  to  catheter- 


DIAGNOSIS  297 

ism.    Spontaneous  infection  does  occur,  but,  as  a  rule,  the  complication 

is  due  to  the  surgeon's  misfortune  or  fault. 

Inflammation  of  the  Prostate — Chronic  prostatitis  is  present  in 
every  infected  case ;  indeed,  the  posterior  urethra  and  the  neck  of  the 
bladder  are  the  places  from  which  it  is  least  possible  to  dislodge  the 
inflammation.  Abscess  and  periprostatitis  are  relatively  uncommon. 
Seminal  vesiculitis  is  common  and  usually  unimportant. 

Epididymitis — Epididymitis  may  occur  in  acute  attacks,  spontane- 
ous or  following  instrumentation,  or  it  may  appear  as  a  sluggish,  chronic 
induration  at  one  end  of  the  epididymis,  with  occasional  subacute  or 
acute  attacks  of  recurrent  inflammation.  The  epididymitis  of  the  pros- 
tatic is  especially  prone  to  suppuration. 

Cystitis — Inflammation  of  the  bladder  is  the  most  common  and  im- 
portant complication  of  prostatism.  The  cystitis  is  usually  due  to 
catheterism,  less  frequently  it  is  spontaneous.  When  due  to  the 
catheter,  it  usually  begins  acutely,  often  with  a  chill,  while  spontaneous 
cystitis  is  commonly  chronic  from  the  outset.  Although  the  type  of 
the  inflammation  may  be  severe  throughout,  the  cystitis  of  prostatics 
is  often  of  a  mild  and  superficial  type  for  many  months,  not  causing 
any  gTeat  pain  or  frequency  of  urination,  or,  at  any  rate,  easily  con- 
trolled by  local  treatment.     The  cystitis  may  be  alkaline  or  acid. 

Pyelonephritis. — ISTo  prostatic  can  have  cystitis  for  any  length  of 
time  without  extension  of  the  inflammation  up  the  ureters  to  the  kid- 
neys. The  pyelonephritis  often  remains  for  years  a  mild  inflammation, 
recognizable  only  by  a  careful  urinary  examination;  but,  mild  as  it  is, 
this  inflammation  is  an  aid  to  the  urinary  pressure  in  its  work  of  debili- 
tating the  kidneys  and  slowly  leading  to  the  patient's  death. 

Stone. — The  prostatic  is  peculiarly  subject  to  stone  in  the  bladder. 
Urate  stones  frequently  complicate  cases  with  but  little  retention  and 
slight  infection.  Such  stones  are  not  visible  to  the  x-ray.  If  removed 
by  litholapaxy  they  recur  repeatedly  until  the  prostatic  obstacle  is 
removed.  On  the  other  hand  severe  ammoniacal  cystitis  is  often  a  sign 
of  phoophatic  stone. 

Hematuria,  severe  cystitis,  and  diurnal  frequency  of  urination 
may  suggest  the  presence  of  stone;  but  if  this  lies  behind  a  large 
prostate  it  often  does  not  irritate  the  bladder  neck  and  its  presence  is 
not  suspected  until  disclosed  by  cystoscopy  or  operation. 


DIAGNOSIS 

Rectal  Examination — When  a  patient  over  fifty  years  of  age  com- 
plains of  frequent  micturition,  suspicion  falls  at  once  upon  the  pros- 
tate.    It  is  rare  that  stricture  causes  trouble  for  the  first  time  so  late 


•298  '  PROSTATISM 

in  life,  and  even  rarer  for  prostatic  retention  to  occur  earlier;  more- 
over, with  enlarged  prostate,  the  inconvenience  will,  as  a  rule,  have 
been  first  noticed  at  night — the  reverse  of  what  is  observed  in  stricture. 
As  the  first  step  in  the  examination,  a  digital  exploration  should  be 
made  through  the  rectum.  Bj  this  means  alone  prostatic  hypertrophy 
can  almost  always  be  demonstrated.  In  place  of  the  soft,  chestnutlike 
body,  hardly  recognizable  except  by  the  skilled  touch,  the  finger  en- 
counters a  rounded,  dense  mass,  smooth  and  usually  symmetrical.  The 
median  fissure  between  the  lobes  may  be  more  than  usually  perceptible, 
or  may  be  wholly  obliterated ;  while  the  finger  passed  up  on  each  side, 
between  the  prostate  and  the  walls  of  the  pelvis,  recognizes  a  deepening 
of  the  sulcus,  an  undue  prominence  in  size  of  one  or  both  lobes,  an 
enlargement  of  the  gland  both  from  side  to  side  and  from  above  down- 
ward. If  very  large,  it  may  be  impossible  to  hook  the  last  phalanx 
above  the  margin  of  the  enlarged  prostate. 

If  only  the  median  lobe  is  enlarged,  or  if  the  prostate  is  sclerotic, 
rectal  examination  reveals  no  positive  evidences  of  this  enlargement. 

Hypogastric  Palpation. — If  the  bladder  is  distended  with  urine,  an 
oval  tumor  is  found,  filling  up  the  lower  part  of  the  belly,  perhaps  as 
high  as  the  umbilicus,  flat  on  percussion,  and  causing  a  desire  to  urinate 
when  pressure  is  made  upon  it.  This  tumor,  formed  by  the  overdis- 
tended  bladder,  may  sometimes  be  plainly  seen,  but  the  patient  is 
usually  unconscious  of  its  existence.  The  full  bladder  may  be  palpated 
between  a  finger  in  the  rectum  and  a  hand  on  the  hypogastrium. 

The  Urine. — The  patient  is  now  asked  to  stand  up  and  to  pass 
water  into  a  glass  vessel.  As  the  urine  flows  the  sluggishness  of  the 
stream  is  noted. 

If  there  is  complete  retention,  the  urine  will  not  flow  at  all,  or 
comes  only  by  drops.  While  the  stream  is  flowing,  if  the  patient  strains, 
instead  of  becoming  larger  or  flowing  with  greater  force,  it  may  be 
diminished  in  size  and  power.  If  the  bladder  be  inflamed,  there  may 
be  severe  tenesmus  and  pain  during  the  attempt  to  urinate,  and  the 
rectum  may  protrude  or  feces  be  passed  during  the  act.  Hernia  may 
also  result.  At  the  end  of  urination  the  stream  gTadually  dribbles  away 
in  drops,  and  often  the  final  jet  is  wanting. 

If  the  urine  be  now  held  up  to  the  light,  its  cloudiness  or  limpidity 
proves  an  index  to  the  presence  or  absence  of  urinary  infection. 

Catheterism. — If  the  urine  passed  is  purulent,  or  if  no  iirine  can 
be  passed,  the  quicker  the  patient  is  catheterized  the  better.  But  if  ihe 
urine  contains  no  pus,  infection  ivill  follow  catheterism.  Hence  the 
operation  in  such  cases  should  be  guarded  by  the  most  minute  pre- 
cautions, viz.,  hexamethylenamin,  gentleness,  antisepsis. 

The  choice  of  catheter  is  important.  A  smooth  soft-rubber  instru- 
m.ent  will  usually  enter  the  bladder,  but  not  always.    A  "natural  curve" 


DIAGNOSIS  299 

woven  catheter  will  enter  the  bladder  of  any  prostatic  whose  condition 
is  not  complicated  by  previous  efforts  at  instrumentation,  or  by  carci- 
noma, stone  or  stricture.  jSTo  force  should  be  employed  in  introducing 
the  instrument.  Dexterity  and  patience  will  succeed  where  brute  force 
will  only  light  up  inflammation  or  open  a  false  passage. 

The  amount  of  residual  urine  measures,  in  a  general  way,  the 
amount  of  retention,  though  this  must  be  repeatedly  verified. 

The  urethral  length  is  also  measured  by  the  catheter.^  One  usually 
feels  the  resistance  of  the  cut-off  muscle  very  plainly  in  entering,  and  if 
the  urethral  length  is  not  increased,  one  expects  to  strike  water  5  to  6 
cm.  beyond.  If  the  cut-off  is  not  felt,  one  measures  the  total  urethral 
leng-th  upon  withdrawing  the  catheter.  On  account  of  the  variable 
length  of  the  anterior  urethra  the  latter  method  is  the  less  reliable. 

In  thus  emptying  the  patient's  bladder  two  rules  must  be  borne  in 
mind: 

1.  Close  the  operation  hy  a  mild  antiseptic  irrigation  (nitrate  of 
silver,  1:4,000). 

2.  If  the  bladder  retains  more  than  500  c.c.  of  urine  the  result  of 
emptying  it  with  the  catheter  is  likely  to  be  a  sufficient  congestion  of 
the  bladder  neck  to  induce  acute  complete  retention.  The  patient's 
comfort  and  safety,  perhaps  even  his  life,  depend  upon  the  intelligence 
with  which  he  is  now  managed  during  the  first  few  days.  Diagnosis 
merges  immediately  into  treatment  and  neglect  of  this  treatment  may 
have  fatal  results. 

3.  The  traditional  danger  of  suddenly  emptying  a  bladder  that  has 
retained  more  than  a  liter  is  real  enough,  but  the  cause  of  it  has  been 
misunderstood.  The  patient  suffers,  not  because  his  bladder  has  been 
emptied,  but  because  having  once  been  emptied  it  is  not  kept  empty. 
The  first  catheterization  is  usually  performed  with  the  patient  lying 
down  and  he  need  only  be  kept  upon  his  back  until  such  faintness  as 
he  may  feel  from  the  relief  of  intra-abdominal  pressure  shall  be  re- 
lieved. But  if  the  amount  of  retained  urine  is  very  great  the  back 
pressure  upon  the  kidneys  has  been  equally  great  and  their  suscepti- 
bility to  immediate  infection  is  proportional.  The  subsequent  treatment, 
therefore,  must  be  carried  out  with  particular  care,  but  the  refilling  of 
the  bladder  with  enough  fluid  to  minimize  the  supposed  shock  of 
emptying  this  organ  is  no  part  of  that  treatment. 

Cystoscopy. — ISTone  but  the  expert  should  attempt  cystoscopy  in 
cases  of  prostatic  retention.  The  operation  is  dangerous  to  the  patient 
and  is  calculated  to  give  little  information  to  the  unskilled  manipulator. 
But  to  the  specialist,  cystoscopy  is  of  the  greatest  service.  It  permits  a 
more  thorough  appreciation  of  intravesical  conditions  than  is  attainable 

*  Special  instruments  devised  for  this  purpose,  such  as  those  of  Hagner  and 
Cunningham,  are  not  necessary. 


300  PROSTATISM 

by  any  other  means ;  it  searches  for  stone  much  more  thoroughly  than 
does  the  stone  searcher ;  it  also  gives  a  very  fair  estimate  of  the  form 
of  the  prostatic  obstruction. 

Cystoscopy  should  be  performed  only  for  the  diagnosis  of  stone, 
or  as  a  preliminary  to  operation.  For  the  diagnosis  of  stone  it  is  re- 
quired in  all  infected  cases.  The  introduction  of  the  instrument  may 
be  exceptionally  difficult  on  account  of  the  prostatic  obstruction,  but 
this  may  almost  always  be  overcome  by  depression  of  the  ocular  extrem- 
ity of  the  instrument.     The  picture  seen  has  been  described  on  p.  62. 

Urinalysis. — Inspection  of  the  urine  is  an  essential  part  of  the  ex- 
amination. The  specimen  should,  of  course,  be  submitted  to  routine 
examination,  and  the  division  of  a  twenty-four-hour  specimen  into  day 
and  night  is  of  great  service  in  estimating  the  presence  of  nocturnal 
polyuria. 

The  phenolsulphonephthalein  test  and  the  estimation  of  blood  pres- 
sure form  a  part  of  the  routine  examination. 

The  Phenolsulphonephthalein  Test. — The  condition  of  the  kidneys 
is  best  estimated  by  the  phenolsulphonepththalein  test.  Even  before 
the  retention  has  become  complete,  this  test  shows  some  impairment  of 
the  kidney  function  and  the  output  in  the  first  hour  after  intramuscular 
injection  usually  varies  between  25  and  35  per  cent.  Acute  retention, 
if  brief  and  promptly  and  completely  relieved,  has  very  little  depress- 
ing effect  upon  the  kidney  function  as  tested  by  the  phenolsulphone- 
phthalein test.  But  chronic  retention,  however  silent,  greatly  impairs 
the  capacity  of  the  kidney  to  secrete  phenolsulphonephthalein.  The 
typical  hospital  case  enters  the  wards  within  twenty-four  hours  of  the 
time  that  he  has  been  more  or  less  completely  relieved  of  an  acute  re- 
tention capping  a  slight  chronic  retention  of  some  years^  duration.  His 
kidney  function  may  be  as  low  as  5  or  10  per  cent  in  ihe  first  hour, 
even  lower.     This  is  the  red  danger  signal  (p.  78). 

Other  Methods  of  Examination. — According  to  the  information 
obtained,  we  examine  the  patient  still  further — palpate  the  kidneys, 
submit  him  to  x-ray  or  ureteral  catheterism,  or  to  various  renal  func- 
tion tests.  For  the  fact  that  the  prostate  is  large  is  of  course  the  least 
important  feature  of  the  picture.  The  condition  of  the  patient's  bladder 
is  more  important  than  that  of  his  prostate ;  the  condition  of  his  kidneys 
more  important  than  either;  the  condition  of  his  general  health  most 
important  of  all. 

DIFFERENTIAL  DIAGNOSIS 

When  a  patient  over  fifty  years  of  age  complains  of  nocturnal  fre- 
quency of  urination  wc  mentally  set  him  down  as  a  prostatic.  Yet  the 
inference  is  by  no  means  strict.     KSurely  two  out  of  five  cases  of  noc- 


DIFFERENTIAL  DIAGNOSIS  301 

turnal  frequency  are  due  to  other  causes,  sucli  as  nocturnal  poly- 
uria, prostatic  carcinoma,  or  urethral  stricture.  The  average  pros- 
tatic begins  to  suffer  between  fifty-five  and  sixty-five,  and  first  con- 
sults a  physician  at  about  the  latter  age.  The  patient  who  does  not 
begin  to  suffer  until  after  he  is  seventy  years  old  usually  has  carcinoma. 
Moreover  it  is  not  to  be  forgotten  that  occasionally  prostatic  retention 
occurs  in  young  men  twenty  or  thirty  years  before  the  prostatic  age. 

Careful  physical  examination  rules  out  such  conditions  as  stricture 
and  nocturnal  polyuria.  But  four  conditions  causing  the  symptoms  of 
prostatism  are  very  commonly  confused.  Indeed,  it  may  for  a  long 
time  be  difficult  in  a  given  case  to  make  the  diagnosis  absolute  among 
them.     These  conditions  are: 

Prostatism  (adenomatous  or  sclerotic). 
Prostatic  neoplasm. 
Paralysis  of  the  bladder. 
Prostatic  calculus. 
Prostatism  may  usually  be  distinguished  from  the  other  four  as 
follows : 

Prostatic  Neoplasm — To  distinguish  prostatism  from  prostatic  neo- 
plasm always  requires  careful  rectal  examination,  sometimes  cystoscopy, 
and  occasionally  the  test  of  time  (p.  315).  Spontaneous  hemorrhage 
is  suggestive  of  prostatism  rather  than  of  malignancy. 

Paralysis  of  the  Bladder — ^When  there  is  retention  of  urine,  but  no 
urethral  stricture,  and  no  palpable  prostatic  enlargement,  the  follow- 
ing possibilities  must  be  contemplated: 

1.  There  may  be  paralysis  of  the  bladder.  This  is  commonly  due 
to  tabes,  shows  a  rather  suggestive  cystoscopic  picture,  and  is  dis- 
tinguished by  the  reflex  changes  and  the  examination  of  the  spinal 
fluid  (p.  469). 

2.  There  may  be  carcinoma.  Careful  palpation  then  reveals 
nodules,  and  a  thickening  of  the  posterior  lobe. 

3.  There  may  be  a  pedunculated  middle  lobe  or  a  bar,  visible  by 
cystoscopy. 

4.  Rarest  of  all,  and  oftenest  in  relatively  young  men,  we  encounter 
the  type  of  sclerotic  prostate  that  shows  no  characteristic  change  to 
cystoscopy  or  to  rectal  touch.  The  existence  of  this  condition  can  only 
be  affirmed  after  tabes  has  been  excluded  by  the  most  rigid  tests. 

Prostatic  Calculi. — Inasmuch  as  prostatic  calculi  may  give  no  sub- 
jective symptoms  at  all,  or  may  produce  only  a  vesical  irritability,  while 
for  objective  sign  they  cause  enlargement  of  the  prostate,  it  is  quite 
possible  to  mistake  calculi  for  prostatism.  Yet  I  have  not  known  this 
to  be  done;  indeed,  the  irregular  outline  of  the  prostate  containing 
many  calculi  is  usually  such  as  to  suggest  neoplasm  rather  than 
prostatism. 


302  PROSTATISM 


PROGNOSIS 


In  the  First  Stage. — Inasmiicli  as  the  majority  have  no  symptoms 
at  all,  and  an  indefinitely  large  proportion  of  others  have  only  slight 
symptoms  for  many  years,  one  may  be  optimistic  ahont  the  prospects 
of  the  prostatic  who  is  seen  in  the  first  stage  of  his  disease. 

About  50  per  cent  of  prostatics  have  acute  retention,  and  the  great 
majority  of  these  reach  chronic  complete  retention  within  five  or  six 
years.  On  the  other  hand,  I  have  followed  one  case  fourteen  years,  from 
his  single  acute  prostatic  retention,  and  seen  no  return  of  symptoms. 
A  number  of  other  cases  I  have  followed  more  than  five  j^ears.  The 
younger  the  case,  the  slower  the  average  progTess  of  the  disease.  The 
prostatic  who  begins  to  have  symptoms  at  or  beyond  the  age  of  seventy 
usually  reaches  chronic  complete  retention  within  two  years. 

In  the  Second  Stage. — When  the  patient  is  in  chronic  incomplete 
retention,  his  prognosis  is  gradual  failure  of  the  bladder  and  passage  to 
chronic  complete  retention  more  or  less  rapidly,  according  to  his  age, 
his  infection,  the  shape  of  the  prostatic  obstruction  and  the  irritability 
of  the  prostatic  urethra. 

In  the  Third  Stage — ^AYhen  the  patient  has  reached  chronic  com- 
plete retention,  his  expectation  of  life  depends  upon  his  treatment.  The 
patient  who  refuses  operation  and  neglects  himself  speedily  comes  to 
gTief.  The  patient  who  takes  care  of  himself  may  come  to  gTief  by 
unavoidable  accident.  But  the  passage  of  the  catheter  to  empty  a 
bladder  in  retention  is  not  in  itself  necessarily  fatal.  Indeed,  the  pa- 
tient who  empties  his  bladder  three  or  four  times  a  day  by  means  of 
the  catheter  is  in  no  worse  condition  than  the  patient  who  empties  his 
bladder  the  same  number  of  times  without  a  catheter,  excepting  only 
that  the  passage  of  the  instrument  is  more  or  less  irritating.  I  know 
a  number  of  men  who  have  employed  a  catheter  with  entire  satisfaction 
for  more  than  ten  years,  and  one  of  my  patients  died  of  renal  insuffi- 
ciency after  more  than  forty  years  of  catheter  life.  Yet  sooner  or 
later,  in  spite  of  all  our  care,  inflammatory  or  renal  complications 
destroy  the  patient  unless  he  submits  to  operation. 

Prognosis  as  Regards  Infection.^The  prostatic  who  constantly 
passes  the  catheter  is  doomed  to  infection  in  spite  of  whatever  precau- 
tions he  may  take.  Aseptic  rules  of  catheterism  are  solely  for  the  pur- 
pose of  making  this  infection  as  mild  as  possible.  The  infection  always 
occurs  within  a  month  or  two,  usually  within  a  week  or  two,  of  the  be- 
ginning of  catheterism.  We  look  for  it  and  are  happy  to  see  it  pass, 
since  it  establishes  the  patient  in  a  condition  which  either  is,  or  may 
usually  be  reduced  to,  a  mild  acid  cystitis. 

The  larger  the  prostate,  the  more  likely  is  the  infection  to  be  difficult 


PROGNOSIS  303 

to  control.  Careful  patients  with  paralyzed  bladders  and  complete  re- 
tention without  enlargement  of  the  prostate  do  much  better,  as  a  rule, 
than  prostatics;  for  the  prostate  is  a  constant  source  of  infection  and 
trauma. 

Infection  of  the  kidneys  and  ureters  establishes  itself  at  about  the 
same  time  as  infection  of  the  bladder.  It  is  quite  as  difficult  to  dis- 
lodge ;  but  if  the  retention  is  well  managed,  so  that  the  kidneys  do  not 
suffer  much  back  pressure,  it  is  easy  to  control  for  a  time,  at  least. 

Prognosis  as  Regards  Kidneys — Most  prostatics  who  are  not  re- 
lieved of  their  retention  by  operation  die  by  urinary  septicemia  with 
pyelonephritis.  The  issue  may  be  rapid  or  slow.  Watson  ^  collected 
207  cases  of  prostatism  treated  by  the  catheter,  with  a  little  less  than  8 
per  cent  mortality  within  a  month.  But  the  more  usual  danger  from 
the  kidneys  is  slow,  insidious  failure  due  to  mild  retention  and  mild 
infection. 

-ATinals  of  Surgery,  1904,  June,  p.  853. 


CHAPTER   XXXI 

TREATMENT  OF  PROSTATISM 

PROSTATIC  HYGIENE 

The  prostatic  man  resembles  tlie  menstruating  woman  in  that  any 
exposure  or  overdoing  reacts  promptly  upon  his  pelvic  organs.  "Be- 
ware of  congestion"  must  be  his  motto,  and  upon  this  he  must  mold 
his  life.  He  must  avoid  all  exposure  to  cold :  draughts  are  dangerous, 
wet  feet  fatal.  His  clothing,  especially  his  underwear  and  footgear, 
must  be  regulated  by  the  thermometer.  Light  exercise  and  fresh  air 
are  beneficial;  but  any  excess — physical,  mental,  sexual,  or  alcoholic — - 
must  be  avoided.  Of  alcoholic  beverages,  he  may  drink  whisky,  gin, 
and  white  wine  in  moderation;  but  preferably  no  beer  or  champagne. 
The  stomach  must  not  be  overloaded.  "C'est  souvent  en  lui  souhaitant 
tonne  fete"  says  Guyon,  "quon  determine  chez  un  vieillard  prostatique 
sa  premiere  retention/'  The  diet  must  be  both  light  and  laxative,  for  a 
torpid  bowel  threatens  infection  as  well  as  congestion.  Meats  should 
be  largely  replaced  by  vegetables  and  cereals.  Finally,  the  patient 
must  keep  his  urine  bland  by  drinking  plenty  of  water. 


GENERAL  TREATMENT 

If  the  prostate  is  simply  congested,  the  urine  clear,  the  residuum 
negligible,  there  may  be  marked  irritability  of  the  bladder  with  frequent 
and  painful  urination.  To  conquer  this,  hexamethylenamin  (0.5  to  1 
gram),  t.  i.  d.  (though  it  may  irritate),  and  sedatives  are  efficacious. 
Instillations  of  10  per  cent  argyrol  or  1  per  cent  phenol  are  also  useful. 

If  there  is  retention  without  infection,  the  patient  should  be  con- 
stantly on  hexamethylenamin  to  prevent  infection  so  long  as  any  local 
treatment  is  being  employed,  and  it  is  probably  better  that  he  should 
take  a  little  of  the  drug  at  all  times,  if  there  is  more  than  50  c.c.  of 
residuum. 

If  there  is  infection,  the  treatment  is  that  of  prostatitis  or  'of  re- 
tention cystitis,  as  the  case  may  be.  Hexamethylenamin  is  again  the 
backbone  of  the  treatment.     It  mav  be  siven  for  short  neriods  of  time 

304 


LOCAL  TREATMENT  AND  OPERATION  305 

in  doses  as  high  as  the  patient  can  bear,  in  the  hope  of  controlling  the 
infection. 

The  treatment  of  renal  infection  is  fully  detailed  elsewhere  (p. 
361). 

The  bowels  and  stomach  often  require  special  attention  by  cathartics, 
vegetable  and  saline,  enemata,  gastric  lavage,  etc. 

Opiates. — A  final  word  on  the  subject  of  opiates.  Prostatism  is  a 
chronic  disease,  and  pursues  a  most  uncertain  course.  The  sufferer, 
writhing  in  agony  today,  may  be  entirely  relieved  tomorrow.  The 
patient  whose  last  sun  seems  to  have  risen  may  be  relieved  by  operation, 
and  survive  for  many  a  year.  Under  these  circumstances,  it  is  scarcely 
necessary  to  insist  that  opiates  should  be  administered  with  extreme 
caution.  The  patient,  a  constant  sufferer  from  a  tormenting  disease, 
is  in  an  ideal  condition  to  become  addicted  to  narcotics.  I  have  seen 
few  sadder  cases  than  those  of  old  men  whose  prostatic  disease  was  still 
curable,  while  their  subjection  to  narcotics  could  not  be  overcome. 


LOCAL  TREATMENT  AND  OPERATION 

LOCAL  TREATMENT 

First  Stage. — During  the  first  stage  of  the  disease  the  bladder 
empties  itself.  Catheterization  is  therefore  quite  unnecessary ;  indeed, 
it  may  be  harmful.  Bladder  irritation  must  be  treated  by  instillations 
of  argyrol  or  carbolic  acid,  or  by  prostatic  massage  and  the  rectal 
douche.  It  is  the  relief  of  this  condition,  by  the  way,  that  is  accom- 
plished by  the  vaunted  electrical,  hydrotherapic  and  manipulative  cures 
of  prostatism. 

Acute  Retention. — The  urine  must  be  withdrawn.  Half-hearted 
measures  are  inefficient.  The  hot  sitz  bath  may  be  employed  with  a 
hypodermic  injection  of  morphin  as  a  temporizer;  but  the  patient,  once 
thoroughly  obstructed,  is  quite  beyond  emptying  his  own  bladder.  The 
surgeon  must  do  that  for  him. 

There  are  only  two  requirements:  (1)  Absolute  cleanliness,  and 
(2)  keeping  the  bladder  empty.  Under  the  head  of  absolute  cleanli- 
ness must  be  included  irrigation  of  the  meatus  before  catheterization, 
and  of  the  bladder  afterwards,  as  well  as  the  administration  of 
hexamethylenamin. 

After  the  passage  of  the  catheter  one  gram  of  hexamethylenamin 
is  administered  as  soon  as  possible  and  the  dose  repeated  three  times  a 
day  thereafter.  The  patient  is  immediately  sent  home  to  bed  and  if 
possible  put  under  the  care  of  a  skilled  nurse  who  promptly  administers 
a  hot  rectal  irrigation  and  is  ready  with  the  catheter  in  case  the  patient 
cannot  urinate.     If  the  patient  urinates  comfortably  after  one  or  two 


306  TREATMENT  OF  PROSTATISM 

catheterizations  no  further  treatment  is  necessary  so  long  as  the  bladder 
is  found  to  empty  itself. 

But  if  the  retention  continues  the  patient  must  be  disabused  of  the 
false  hope  that  he  can  get  along  better  without  the  catheter  than  with 
it.  Quite  the  contrary  is  the  actual  case.  The  more  he  depends  upon 
the  catheter,  the  more  likely  is  he  to  be  relieved  of  his  acute  retention, 
or  in  case  this  is  not  to  be,  the  safer  he  is  in  that  retention. 

The  choice  of  the  means  of  keeping  the  patient's  bladder  empty 
depends  upon  the  circumstances.  In  my  hospital  practice  I  usually 
tie  a  catheter  into  the  urethra  of  every  case  of  acute  complete  retention, 
administer  hexamethylenamin,  keep  the  patient  in  bed,  take  a  phenol- 
sulphonephthalein  test,  and  await  the  resulting  infection.  Within  the 
next  few  days  the  patient  has  a  rise  of  temperature,  perhaps  a  chill  or 
a  series  of  chills,  but  if  the  catheter  drains  well  and  the  bladder  is 
irrigated  with  1 :  4,000  silver  nitrate  solution,  once  a  day,  and  hexa- 
methylenamin kept  up,  the  infective  reaction  (cf.  p.  349)  is  likely  to  be 
relatively  mild  and  brief,  unless  the  patient's  condition  is  very  bad. 
In  the  course  of  a  week,  however,  the  phenolsulphonephthalein  output 
drops  with  the  advent  of  acute  infection,  stays  low  for  a  few  days,  and 
then  usually,  during  the  second  week,  begins  to  rise,  reaches  its  pre- 
vious height  and  often  exceeds  this.  By  the  time  the  phenolsulphone- 
phthalein output  has  become  apparently  stationary  and  any  excessive 
polyuria  has  disappeared  and  the  blood  urea  nitrogen,  the  blood  pres- 
sure, etc.,  have  been  carefully  examined,  and  a  cystoscopy  performed, 
the  patient  is  ready  for  operation  (which  is  always  urged  upon  hos- 
pital cases).  If  the  retained  catheter  does  not  work  well  on  the  hos- 
pital case,  the  bladder  is  opened  above  the  pubes  and  drained  until 
conditions  become  stationary. 

In  private  practice  it  is  usually  more  satisfactory  to  have  an  expert 
nurse  pass  the  catheter  as  frequently  as  may  be  required,  rather  than 
to  depend  upon  the  indwelling  catheter  or  the  suprapubic  drainage. 
During  the  first  few  days  it  is  usually  an  excellent  rule  to  have  the 
catheter  passed  every  time  the  patient  feels  the  least  inclination  to 
urinate.  By  this  time  some  system  will  have  been  established  whereby 
the  catheter  can  be  passed  at  regular  hours  just  ahead  of  the  prospective 
desire  to  urinate.  The  bladder  is  washed  twice  a  day,  phenolsulphone- 
phthalein test  and  hexamethylenamin  administration  conducted  as 
above  described.  The  patient  is  confined  to  the  house  but  not  to  his  bed. 
If  he  weathers  his  attack  well  and  thereafter  empties  his  bladder  he 
does  not  absolutely  need  operation,  though  even  he  is  perhaps  better  oft" 
if  operated  upon,  since  sooner  or  later  retention  will  recur.  But  if 
complete  retention  continues  I  always  ardently  urge  operation  as  a 
lesser  danger  than  catheter  life,  unless  the  patient's  general  condition  is 
such  as  to  make  the  operative  risk  most  unusually  great. 


LOCAL  TREATMENT  AND  OPERATION  307 

A  low  phenolsulphoneplithalein  output  is  no  contra-indication  to 
operation,  if  other  conditions  are  satisfactory  and  if  the  acute  condition 
of  renal  reaction  following  the  first  catheterization  has  been  passed. 
Indeed  patients  in  catheter  life  who  have  long  been  infected  and  are 
accustomed  to  a  certain  moderate  retention  of  urine  may  often  be  op- 
erated upon  safely  with  almost  no  preparation  whatsoever.  It  is  the 
uninfected  cases  with  acute  retention  that  are  likely  to  do  badly  by 
renal  defect  if  operated  upon  too  precipitately.  One  prefers  to  have 
the  phenolsulphonephthalein  test  as  high  as  possible  before  operation; 
but  when  this  has  become  stationary,  at  whatever  intensity,  operation  is 
justifiable. 

ISTeither  age  nor  debility  are,  of  themselves,  essential  contra-indi- 
cations  to  operation.  Yet  I  confess  to  a  certain  human  sympathy  with 
patients  75  or  80  years  of  age.  I  prefer  to  let  them  have  their  few 
years  of  catheter  inconvenience  rather  than  to  submit  them  to  the  tur- 
moil of  operation. 

Catheter  Life. — Patients  by  whom  operation  is  refused  or  to 
whom  operation  seems  unsuited  may  employ  the  catheter.  Before  this 
is  agreed  to  cystoscopy  should  be  performed  so  that  one  may  be  con- 
versant with  the  conditions  inside  the  bladder  as  to  diverticulum  and 
stone,  as  well  as  size  and  shape  of  the  prostate  itself. 

The  ancient  rules  as  to  the  frequency  with  which  the  catheter  should 
be  passed  are  never  followed  by  the  patient.  If  the  amount  of  residual 
urine  is  small  and  the  bladder  irritability  slight  the  patient  will  refuse 
to  pass  his  catheter  more  than  once  or  twice  a  day.  But  as  a  rule  he 
promptly  goes  into  chronic  complete  retention  and  then  should  be  urged 
to  pass  the  catheter  often  enough  to  forestall  urination.  The  tradi- 
tional three  times  in  the  twenty-four  hours  are  usually  not  sufficient; 
from  four  to  six  times  are  better. 

The  patient  might  add  many  years  to  his  life  by  being  aseptic  and 
gentle,  but  the  average  man  cannot  be  bribed  into  either  virtue  by  the 
promise  of  longevity.  He  totally  neglects  asepsis  and  uses  his  catheter 
like  the  ramrod  of  a  gain.  Some  urethrae  will  withstand  a  marvellous 
amount  of  such  rough  treatment,  but  the  majority  will  not  and  their 
owners  die  miserably. 

The  patient  should  be  instructed  always  to  keep  the  head  of  his 
penis  clean  and  to  wash  his  own  hands  well  before  touching  the  catheter. 
He  should  use  a  rubber  catheter  if  possible,  keeping  a  number  of  these 
in  stock,  so  that  they  may  be  all  boiled  together  and  laid  between  the 
folds  of  a  sterile  towel,  to  be  carried  about  and  used  when  necessary, 
one  by  one.  In  order  to  catheterize  himself,  the  patient  washes  Iiis 
hands,  takes  his  tube  of  sterile  lubricant,  anoints  with  it  the  end  of 
his  catheter,  mops  the  lubricant  from  the  catheter  to  the  end  of  the 
penis  holding  the  catheter  at  a  point  at  least  two  inches  from  its  extrem- 


308  TREATMENT  OF  PROSTATISM 

it  J  and  never  touching  those  terminal  two  inches.  He  passes  the 
catheter  slowly  into  the  bladder  up  to  the  point  where  it  just  draws 
water,  holds  it  there  until  the  bladder  is  empty,  then  withdraws  it. 
Once  a  day  he  irrigates  his  bladder  with  1 :  4,000  solution  of  silver 
nitrate  using  for  this  purpose  a  douche  bag  and  filling  the  bladder  to 
the  point  of  comfort  two  or  three  times.  It  is  preferable  that  the  patient 
wash  his  bladder  every  day,  for  if  any  exception  is  made  he  will  probably 
stop  washing  altogether.  After  the  first  acute  renal  infection  has  gone 
by,  if  he  is  faithful  and  gentle  with  his  catheter  and  irrigation,  I  see 
no  advantage  in  the  administration  of  hexamethylenamin.  Indeed 
the  patient  himself  will  soon  desist  from  its  use  if  it  is  advised.  (Ex- 
ceptionally, however,  the  hexamethylenamin  keeps  the  patient  clean 
better  than  the  bladder  wash.)  The  patient  who  has  to  use  a  woven 
catheter  certainly  ought  to  be  operated  upon  or  else  have  a  trained 
nurse  constantly  at  hand  to  pass  the  catheter.  Otherwise  he  will  simply 
punch  holes  in  his  urethra  and  cause  both  himself  and  his  physician 
untold  trouble. 

RADICAL  OPERATIONS 

Obsolete  operations — 

Castration  and  vasotomy. 
Bottini's  operation. 
Pseudoradical  operations — 

Chetwood's  galvanocauterization. 
Young's  punch  operation. 
Goldschmidt's  and  Bugbee's. 
Radical  operations — 

Intra-urethral  perineal  prostatectomy. 
Extra-urethral  perineal  prostatectomy. 
Suprapubic  prostatectomy. 
The  Obsolete  Operations — Castration,  vasotomy,  and  Bottini's  op- 
eration have  been,  to  all  intents  and  purposes,  discarded.     Although 
the  two  former  have  manifest  influence  in  the  reduction  of  the  conges- 
tion of  the  prostate  gland,^  it  is  questionable  whether  they  ever  cause 
the  prostate  to  atrophy,  and  it  is  certain  that  whatever  atrophy  they 
do  cause  does  not  necessarily  relieve  the  obstruction  to  urination,  and 
has  no  effect  upon  the  debilitated  bladder. 

Bottini's  operation  fails  to  fulfill  the  siTrgical  indications.  It  is  an 
attack  upon  the  prostate  undertaken  through  the  urethra  without  digital 
examination  of  the  precise  nature  of  the  obstruction,  and  without  the 
possibility  of  verifying  the  fact  that  the  obstruction  has  been  relieved 
after  the  operation  is  completed.  The  surgeon  does  not  know  precisely 
what  he  is  trying  to  do,  nor  precisely  what  he  has  done.  The  relief  of 
*Cf.  Keyes,  Jr.,  Med.  Becord,  1900,  July  21,  p.  81. 


LOCAL  TREATMENT  AND  OPERATION  309 

obstruction  is  scarcely  ever  permanent  and  even  temporary  relief  cannot 
be  predicted  with  an}^  certainty. 

Although  the  mortality  of  Bottini's  operation  is  low  (2  to  6  per 
cent),  the  cases  that  die  are  often  those  that  could  readily  be  saved  by 
some  other  operation. 

Pseudoradical  Operations — These  operations  pretend  to  remove 
small  obstructions  with  a  minimum  danger  to  life.  They  all  require 
a  very  special  training  and  are  appropriate  for  the  relief  of  only  the 
sclerotic  type  of  obstruction.  Chetwood's  operation  has  a  small  risk  of 
incontinence,  but  provides  excellent  drainage.  Young's  has  the  risk  of 
bleeding  and  the  advantage  (or  disadvantage)  of  permitting  (or  re- 
quiring) multiple  operations.  The  trend  of  surgery  is  against  all  such 
procedures  and  in  favor  of  prostatectomy. 

Mortality  of  Prostatectomy — The  estimated  mortality  of  perineal 
prostatectomy  averages  about  6  per  cent  (Proust^  and  Watson).  Indi- 
vidual operators  have  reported  a  far  lower  mortality.  Thus,  FergTisson 
has  reported  103  cases  with  3.6  per  cent  mortality,  and  Young  has  per- 
formed 128  consecutive  operations  without  a  death,  having  previously 
reported  4.6  per  cent  mortality.  Suprapubic  prostatectomy  has  a 
rather  higher  average  mortality.  Thus,  Freyer  operated  upon  1,000 
cases  with  6  per  cent  luortality.  On  the  other  hand,  the  average  mor- 
tality of  the  specialist  is  10  per  cent,  that  of  the  general  surgeon  nearly 
50  per  cent. 

Inasmuch  as  the  technic  of  prostatectomy  has  only  been  perfected 
within  the  past  few  years,  the  masters  of  each  particular  operation  are 
able  to  report  a  progressively  smaller  list  of  mortality,  both  because 
of  the  improvement  of  their  technic  and  because  they  are  able  to  recog- 
nize those  cases  which  are  in  such  bad  condition  as  to  justify  no  radical 
operation.  -ISTo  man,  attempts  to  remove  the  prostate  of  every  prostatic. 
The  more  conservative  operator  may  well  succeed  in  saving  all  his 
patients,  but  only  at  the  expense  of  permitting  some  to  die  of  their 
disease,  or  to  pass  their  remaining  days  with  a  suprapubic  fistula,  who 
might,  in  the  hands  of  the  bolder  surgeon,  have  been  rid  of  their 
troubles. 

Functional  Results  of  Operation — Suprapubic  prostatectomy  gives 
the  best  functional  results.  If  the  patient  recovers  from  the  operation, 
and  if  the  operation  has  been  properly  performed,  he  may  be  expected 
to  become  entirely  well.  He  runs  no  risk  of  incontinence  of  urine  or 
rectal  fistula,  is  likely  to  empty  the  bladder  completely,  and  careful 
after-treatment  should  minimize  the  one  risk  of  the  operation,  viz.,  pro- 
longed healing  of  the  suprapubic  wound.  On  the  other  hand,  the  supra- 
pubic operation  gives  a  much  more  tedious  convalescence  than  perineal 
prostatectomy. 

^  (Jomptcs  Rendiis  de  V Assoc.  Franc  d'Urol.,  1904,  p.   184, 


310  TREATMENT  OF  PROSTATISM 

Perineal  prostatectomy,  if  entirely  successful,  is  the  most  brilliant 
of  all  the  operations  upon  the  prostate.  It  permits  the  patient  to  be  out 
of  bed  within  a  few  days,  and  cures  him  entirely  within  two  or  three 
weeks ;  but  it  is  a  more  difficult  operation  to  perform  properly  than  is 
suprapubic  prostatectomy.  It  gives  a  small  percentage  of  urethrorectal 
fistulae,  even  when  performed  by  the  best  operators,  and  it  leaves  a  small 
and  indeterminate  number  of  patients  with  incontinence  of  urine,  par- 
tial or  complete,  after  the  operation.  In  short,  more  perineal  cases 
survive,  but  fewer  suprapubics  wish  they  were  dead. 

The  preservation  or  restoration  of  the  sexual  function  has  been 
falsely  claimed  as  the  crowning  glory  of  each  operation  in  turn.  This 
can  never  be  prophesied,  has  no  bearing  upon  the  integTity  of  the 
ejaculatory  ducts,  and  is,  after  all,  a  minor  consideration.  Erections,  if 
lost  before  operation,  are  rarely  restored ;  if  present,  they  are  retained 
in  about  half  the  cases. 

Choice  of  Operation — If  preliminary  cystoscopy  has  not  been, 
or  may  not  be,  performed,  the  suprapubic  operation  is  the  operation  of 
choice,  for  it  alone  permits  a  thorough  study  of  the  precise  nature  of 
the  intravesical  growth  and  a  full  appreciation  of  the  presence  or 
absence  of  stone.  Generally  speaking,  the  surgeon  unfamiliar  with  the 
technic  of  these  various  operations  will  succeed  better  by  the  supra- 
pubic than  by  the  perineal  route.  The  pseudoradical  operations  do  not 
guarantee  a  permanent  cure. 


CHAPTEK    XXXII 

MALIGNANT  NEOPLASMS  OF  THE  PROSTATE'— NEOPLASMS  OF 

THE  URETHRA 

Malignant  disease  of  the  prostate  is  almost  always  primary.  Ex- 
tension of  a  vesical  cancer  to  the  prostate  is  extremely  rare,  while  exten- 
sion of  a  prostatic  growth  to  the  bladder  is  not  uncommon.  Sarcoma 
occurs  in  youth,  carcinoma  in  old  age. 

Sarcoma  is  extremely  rare.  Carcinoma  of  the  prostate  was  found 
43  times  in  38,472  autopsies  (Kuemmell  ^)  ;  21  per  cent  of  all  pros- 
tatic lesions.  The  Mayo  clinic  reports  878  prostatectomies,  of  which 
93  for  carcinoma,  while  84  other  cancers  were  not  operated  upon. 
Young  ^  reported  that  among  500  cases  cancer  was  found  once  for  every 
five  cases  of  prostatism  operated  upon.  IS^euber  *  states  that  prostatic 
cancer  forms  from  1.42  to  2  per  cent  of  all  cancers. 

Sarcoma. — Powers  ^  has  collected  31  cases,  of  which  14  were  small 
round-celled  or  ''mixed"  growths.  Of  the  31,  15  occurred  in  children 
less  than  eight  years  of  age  (three  of  these  in  infants  less  than  a  year 
old),  8  between  the  ages  of  fifteen  and  twenty-five,  and  6  between  the 
ages  of  fifty  and  seventy. 

The  diagnosis  is  at  times  easy,  at  times  difficult.  A  rapidly  growing  tumor 
of  the  prostate  in  a  child  or  youth  is  probably  a  sarcoma.  So,  as  well,  is  a 
rai)idly  growing,  soft,  balloon-like  prostatic  tumor  in  an  adult.  Pain  is  gener- 
ally marked,  and  is  referred  to  the  pubes,  perineum,  and  rectum.  Urinary 
urgency  is  not  generally  present  in  the  early  stages.  As  in  the  case  which 
forms  the  subject  of  this  paper,  an  enormous  growth  may  be  unaccompanied 
by  residual  urine. 

Prognosis  in  these  cases  is  necessarily  bad.  In  each  of  the  authentic  cases 
submitted  to  analysis  by  the  writer  either   (a)   the  disease  went  on  to  a  fatal 

^No  non-malignant  tumors  of  the  prostate  have  any  clinical  significance,  other 
than  the  conditions  described  as  prostatism  in  the  preceding  chapters. 

Cysts  of  the  prostate  merit  passing  mention.  The  urethroscope  sometimes  dis- 
closes small  cysts  in  the  posterior  urethra.  They  are  not  known  to  cause  symptoms. 
They  are  readilj^  destroyed  by  fulguration.  Larger  cysts  have  been  found  post 
mortem  (Cf.  Cunningham,  Surg.,  Gynec.  and  Obstet.,  1915,  xxi,  609).  They  obstruct 
urination,  as  do  retrovesical  echinoeoccus  cysts. 
.  'Surgery,  Gynec.  and  Obstet.,  1915,  xx,  274. 

^Ann.  Surg.,  1909,  L,  1232. 

*Zeitschr.  f.  Urol.  Chir.,  1910,  ii,  405. 

^Annals  of  Surg.,  January,  1908. 

311 


312    MALIGNANT  NEOPLASMS  OF  THE  PROSTATE  AND  URETHRA 

termination,  or  (b)  the  patient  succumbed  to  operation  or  (c)  to  relapse  after 
operation,  or  (d)  the  case  was  reported  simply  as  an  operative  recovery.  (Pow- 
ers.) 

Carcinoma — Carcinoma  occurs  almost  exclusively  after  the  age  of 
fifty.  Thus  Judd  classes  his  93  operated  cases  by  decades,  from  50  to 
90  years,  as  21,  34,  36,  and  2  cases.  He  has  seen  a  few  cases  before 
50.  The  symptoms  of  the  disease  usually  begin  a  decade  later  than 
those  of  prostatism. 

Pathology.- — The  tumor  is  either  medullary  or  adenocarcinoma. 
It  may  occur  alone  or  in  conjunction  with  prostatism.  Geraghty  found 
both  in  75  per  cent  of  his  pathologic  material. 

It  has  been  supposed  that  prostatism  was  the  cause  of  prostatic 
carcinoma.  This  opinion  was  fostered  by  the  absence  of  precise  knowl- 
edge of  the  pathological  differences  between  prostatism  and  carcinoma 
which  led  such  competent  observers,  for  instance,  as  Albarran  and 
Halle  ^  to  estimate  that  they  found  evidences  of  carcinoma  in  14  out  of 
100  cases  of  specimens  of  supposedly  non-malignant  prostates  removed 
at  operation.  These  so-called  carcinomata  were  found  in  the  midst  of 
adenomatous  tissue,  and  have  no  bearing  upon  clinical  carcinoma  of  the 
gland,  for  pictures  closely  resembling  carcinoma  can  be  found  in  many 
non-malignant  pseudo-adenomata.  But  they  are  confined  to  isolated 
sections,  and  do  not  appear  clinically  as  carcinomatous. 

To  Geraghty  we  owe  the  laboratory  confirmation  of  the  fact  which 
has  long  been  clinically  evident  enough  that  carcinoma  and  prostatism 
have  no  direct  relation  to  each  other.  He  has  shown  that  if  we  leave 
apart  these  minute  growths  which  might  be  called  laboratory  carcino- 
mata, and  consider  only  those  that  are  grossly  carcinomatous  to  such  a 
degree  that  the  pathological  condition  can  at  least  be  recognized  in  a 
gross  section,  th&  carcinoma  begins  in  a  portion  of  the  gland  not  affected 
by  prostatism  or  adenomatous  change.^  Carcinoma,  therefore,  has  only 
this  relation  with  prostatism  that  where  the  one  begins,  the  other  does 
not.  Prostatism  affects  the  lateral  lobes  and  posterior  commissure,  as 
we  know. 

Geraghty  found  one  carcinoma  originating  in  the  anterior  commis- 
sure, and  49  originating  in  the  posterior  lobe  (that  part  of  the  prostate 
which  lies  below  the  ejaculatory  duct  and  is  never  affected  by  pros- 
tatism). This  posterior  lobe  extends  from  one  side  of  the  prostate  to 
the  other.  It  is  thickest  at  the  apex,  and  thinnest  at  the  base.  It 
therefore  lies  between  the  examining  finger  and  any  other  portion  of 
the  prostate,  and  if  it  is  carcinomatous,  it  is  impossible  to  distinguish 

^  Guyon's  Annates,  1900,  xviii,  113,  325. 

■•'McGrath  {Jour.  A.  M.  A.,  1914,  Ixiii,  1012)  does  not  wholly  accept  this  con- 
tention. 


MALIGNANT  NEOPLASMS  OF  THE  PROSTATE  AND  URETHRA    313 

by  rectal  touch  whether  the  carcinoma  is  in  the  lateral  lobe  or  else- 
where; one  can  only  feel  the  presence  of  a  hard  nodule.  The  neoplasm 
extends  in  two  directions — it  first  follows  the  ejaculatory  ducts,  break- 
ing through  the  upper  border  of  the  prostate.  Thence  it  slowly  invades 
the  trigone,  but  extends  rapidly  up  between  the  bladder  and  the  seminal 
vesicles,  extending  toward  the  lateral  walls  of  the  pelvis  in  the  sheath 
of  the  vesicle  so  that  the  palpating  finger  from  the  rectum  feels  what 
seems  to  be  a  thickened  and  indurated  vesicle,  while  at  the  same  time 


Fig.  66. — Sagittal  Section  of  Prostate  Illustrating  Origin  of  Carcinoma.  1,  Pos- 
terior Commissure;  3,  Verumontanum ;  4,  Anterior  Bladder  Wall;  6,  Fascia  of  Denon- 
villier;  7,  Utricle;  8,  Posterior  Lobe,  where  Carcinoma  usually  begins;  9,  Trigone;  88, 
Anterior  Lobe;  0,  Urethral  Orifice. 


the  extension  through  the  upper  border  of  the  prostate  can  be  felt  as 
a  hard  ridge  along  this  (Fig.  66). 

In  the  second  place,  the  carcinoma  extends  into  the  lateral  lobe  of 
the  gland  itself,  perhaps  invading  and  replacing  the  lesions  of  pros- 
tatism there.  The  fascia  of  Denonvillier  effectively  prevents  the  exten- 
sion of  the  carcinoma  to  the  rectum  until  very  late  in  the  disea.se.  The 
growth  reaches  the  surface  of  the  urethra  and  tbe  bladder  somewhat 
more  readily,  but  even  this  progress  is  slow  compared  to  its  extension 


314    MALIGNANT  NEOPLASMS  OF  THE  PROSTATE  AND  URETHRA 

within  the  pelvis.  It  is  not  uncommon  for  the  carcinoma  to  cause  reten- 
tion of  urine  while  no  ulceration  is  present  and  no  hematuria  has  oc- 
curred. If  rectal  stricture  occurs,  this  is  likely  to  be  high  up  about 
the  upper  extremities  of  the  seminal  vesicles. 

The  pelvic  and  lumbar  glands  are  involved  early,  so  early  indeed 
that  the  patient  may  die  of  glandular  involvement  or  other  metastasis 
before  the  carcinoma  of  the  rectum  has  grown  to  sufficient  size  to  be 
noteworthy. 

According  to  Blumer  ^  bone  metastases  occur  in  two-thirds  of  the 
cases  that  are  not  killed  by  operation. 

MiCEOSCOPiCAL  Diagnosis. — ISTo  amount  of  epithelial  proliferation 
and  piling  up  within  the  acinus  is  evidence  of  carcinoma  of  the  prostate ; 
for  these  changes  may  be  brilliantly  illustrated  in  simple  prostatism. 
It  is  only  when  the  epithelia  break  through  the  stroma  that  carcinoma 
can  be  diagnosticated.  The  pictures  are  often  so  confusing  that  only 
the  most  convincing  evidence  should  be  accepted,  and  this  is  usually 
confirmed  by  the  gross  changes. 

Symptoms. — Cancer  within  the  prostate  gives  either  no  symptoms 
at  all,  or  only  the  vagniest  and  most  unimportant  perineal  discomfort. 
Inasmuch  as  the  primary  growth  may  remain  small  for  many  years, 
bone  or  glandular  involvement  may  predominate  early  in  the  disease. 

Thus  hone  involvement,  secondary  to  carcinoma  of  the  prostate, 
may  be  the  one  clinical  evidence  of  the  disease  during  life ;  this  occurs 
in  a  large  minority  of  cases. 

Sciatica  and  'pelvic  pain,  due  to  involvement  of  the  sacral  plexus  in 
the  glandular  metastases,  is  often  one  of  the  earliest  symptoms.  It 
may  precede  the  urinary  symptoms  by  several  years.  Bilateral  sciatica 
in  an  old  man  is  all  but  pathognomonic  of  prostatic  carcinoma. 

Abdomiiml  tumor,  due  to  carcinoma  of  the  lumbar  glands,  I  have 
once  seen  as  the  predominating  early  symptom  in  a  patient  who  died 
without  ever  having  any  symptoms  directly  referable  to  his  prostate 
beyond  a  very  slight  perineal   discomfort. 

Retention  of  urine,  showing  itself  by  frequency  of  urination,  or 
acute  complete  retention  quite  comparable  to  that  of  simple  prostatism, 
is  often  the  first  symptom  of  carcinoma  of  the  prostate.  The  retention 
of  carcinoma  usually  begins  a  decade  later  than  that  of  prostatism. 

Hematuria  is  a  less  common  symptom  in  carcinoma  than  in  simple 
prostatism.  It  occurs  late  for  reasons  already  stated.  It  was  noted 
in  22  per  cent  of  Judd's  cases. 

Rectal  obstruction  and  ulceration  and  urethrorectal  fistula  are  ter- 
minal complications,  as  are  edemu  of  the  extremities  and  genitals  and 
cachexia. 

Prognosis. — The  disease  is  usually  fatal  in  two  or  three  years. 

^  Bui.  Johns  Hopkins  Univ.,  July,   1909. 


MALIGNANT  NEOPLASMS  OF  THE  PROSTATE  AND  URETHRA    315 

The  most  rapid  case  I  ever  saw  died  within  one  year  of  the  time  that 
my  first  examination  had  left  me  in  doubt  as  to  whether  there  was  a 
small  nodule  of  carcinoma  in  the  prostate  or  not.  On  the  other  hand, 
one  of  my  cases  took  twelve  years  to  die  from  the  time  in  which  I 
diagnosed  carcinoma.  No  attempt  had  been  made  to  remove  the 
growth. 

Diagnosis. — Prostatic  carcinoma  should  be  suspected  whenever  an 
old  man  has  a  bone  tumor,  sciatica  or  pelvic  pain  or  urinary  disturb- 
ances characteristic  of  prostatism. 

The  frequent  association  of  prostatism  with  carcinoma  obscures  the 
diagnosis  unless  this  is  undertaken  methodically.  Young  ^  has  recently 
pointed  out  that  in  early  carcinoma  the  patients  are  absolutely  free 
from  cachexia,  and  practically  free  from  discomfort. 

Rectal  touch  w\\\  usually  disclose  the  presence  of  carcinoma  of  the 
prostate.  Within  the  gland  the  neoplasm  shows  itself  as  one  or  more 
hard  nodules,  one  of  these  being  usually  at  the  apex  of  the  prostate. 
Such  nodules  are  not  pathognomonic ;  they  may  be  due  to  tuberculosis, 
stone  or  ancient  prostatitis.  Unless  other  evidences  of  carcinoma  are 
present  outside  the  prostate,  a  diag-nosis  should  never  be  concluded  with- 
out an  x-ray  examination  for  prostatic  stone,  and  an  examination  by 
rectal  touch  with  a  sound  in  the  urethra.  The  presence  of  the  sound 
brings  out  the  great  hardness  of  the  carcinomatous  nodule  as  well  as 
the  position  at  the  very  apex  of  the  prostate  where  it  joins  the  mem- 
branous urethra  of  the  usual  carcinomatous  infiltration.  Stone  occurs 
only  in  the  lateral  lobes. 

On  the  other  hand,  the  most  convincing  evidences  of  carcinoma  are 
those  that  appear  above  and  beyond  the  prostate.  The  hard  ridge  just 
above  its  upper  edge,  extending  outward  and  sheathing  one  or  both  of 
the  seminal  vesicles  in  a  solid  mass  is  the  pathognomonic  local  sign. 

Cystoscopy  may  reveal  absolutely  nothing.  The  first  intrusion  of 
carcinoma  on  the  bladder  is  in  the  fonn  of  a  bar.  Infiltration  and 
ulceration  of  the  bladder  neck  and  trigone  are  only  seen  quite  late  in 
the  disease. 

Urethral  rigidity  may,,  however,  interfere  with  the  introduction  of 
the  cystoscope  relatively  early. 

Differential  Diagnosis. — The  diagnosis  is  difficult  in  two  classes 
of  cases : 

The  Tumor  Is  Overlooked. — This  happens  when  the  prostate  is  not 
thought  of  as  a  possible  primary  source  of  bone  or  abdominal  carcinoma 
or  as  a  cause  of  sciatica  or  retention  of  urine  or  when  a  careless  examina- 
tion of  a  prostate,  actually  containing  carcinoma,  fails  to  identify  this. 

There  Is  a  Mass  in  the  Prostate. — Distinct  thickening  of  the  apex 
of  the  prostate  is  apparently  never  due  to  anything  excepting  tuber- 

^Am.  Jour.  Urol,  1914,  x,  251. 


316    MALIGNANT  NEOPLASMS  OF  THE  PEOSTATE  AND  URETHRA 

culosis  in  youth,  and  carcinoma  in  age.  Indurations  elsewhere  over  the 
lateral  lobes  may  be  identified  as  carcinoma  by  their  great  hardness 
and  a  negative  x-ray,  by  the  associated  extraprostatic  lesions,  or  by  in- 
filtrations seen  by  cystoscopy. 

Treatment. — The  radical  treatment  of  carcinoma  of  the  prostate 
is  still  indeterminate.  Young  is  enthusiastic  over  total  prostatectomy 
for  the  radical  cure  of  those  whose  disease  has  not  progressed  beyond 
the  limits  of  the  gland.  (It  is,  of  course,  absolutely  impossible  to 
guarantee  the  patient  against  a  metastasis  even  at  this  time. )  Pasteau  ^ 
is  almost  equally  enthusiastic  about  radium.  A  small  experience  with 
both  procedures  leaves  us  in  doubt.  Young's  operation  is  very  likely 
to  result  in  incontinence  of  urine,  though  I  have  one  case  who  made  a 
good  recovery  and  after  a  second  operation — to  close  a  perineal  fistula — 
has  complete  control  of  his  urine.  I  have  seen  brilliant  mitigation  of 
prostatic  carcinoma  by  radium.^  In  view  of  the  gravity  and  danger 
of  operation  the  radium  treatment  is  far  preferable  if  it  is  employed 
with  sufficient  discretion  to  avoid  burns. 

The  pallio.tive  treatment^,  as  in  all  cases  of  carcinoma,  consists  pri- 
marily in  avoiding  operative  interference  as  long  as  possible.  If  there 
is  retention,  the  catheter  must  be  employed,  though  the  encroachment 
of  the  growth  upon  the  urethra  often  makes  catheterism  difficult.  In 
case  the  catheter  fails,  suprapubic  drainage  supplies  relief  of  a  sort, 
though  the  pelvic  pains  continue  and  the  patient  is  likely  to  go  rapidly 
downhill.  On  the  other  hand,  there  is  a  great  array  of  palliative  opera- 
tions whose  success  cannot,  unfortunately,  be  predicated  beforehand. 

Of  every  one  of  these  operations  it  may  probably  be  said  with 
justice,  that  a  very  large  proportion  of  them  actually  do  no  good  to 
the  patient.  They  may  afford  a  temporary  relief  of  symptoms,  and 
this  relief  is  likely  to  continue  for  several  months,  but  no  longer.  Ex- 
ceptionally the  functional  improvement  lasts  for  several  years.  The 
few  cases  in  which  various  palliative  operations  are  alleged  to  have 
cured  carcinoma  of  the  prostate  we  may  well  refuse  to  pass  judg- 
ment upon. 

Each  method  of  prostatectomy  is  praised  as  being  especially  adapted 
to  produce  extraordinary  results  with  carcinoma.  Each  form  of  pros- 
tatectomy has,  in  turn,  received  this  special  praise — intra-urethral  and 
extra-urethral,  perineal  and  suprapubic.  Bugbee  has  reported  very 
satisfactory  results  from  cauterization  of  the  bladder  neck  with  the 
D'Arsonval  current.  He  has  thus  succeeded  in  reducing  the  amount 
of  residual  urine  very  considerably,  and  thereby  increasing  the  patient's 
comfort.     I  have  not  as  yet  been  able  to  duplicate  his  results. 

While  it  is  to  be  frankly  admitted  that  radical  cure  is  impossible 

^Canadian  Practitioner  and  lieview,  1913,  xxxviii,   703. 
^Barringer,  Trans.  Am.  Assn.,  G.-TJ.  Surg.,  1916. 


MALIGNANT  NEOPLASMS  OF  THE  PROSTATE  AND  URETHRA    317 

as  soon  as  the  carcinoma  has  exceeded  the  limits  of  the  prostate,  and 
improbable  in  any  case,  palliative  operations  are  so  much  more  likely 
to  do  harm  than  good,  and  so  unlikely  to  do  anything  more  than  tem- 
porary good,  that  even  in  so  desperate  a  condition  as  carcinoma  of  the 
prostate,  it  seems  unwise  to  interfere  unless  the  patient's  discomfort  is 
very  great.  If,  however,  the  catheter  totally  fails  to  control  the  urinary 
difficulties,  one  may  fairly  waver  between  the  confessed  failure  of  the 
suprapubic  drain,  or  the  attempt  to  give  temporary  relief  by  prostatec- 
tomy.   On  the  whole,  I  favor  the  drain. 


CHAPTEK    XXXIII 
ETIOLOGY  OF  INFECTION  OF  THE  UPPER  URINARY  TRACT 

The  upper  urinary  tract  consists  of  the  kidneys  and  their  ureters, 
the  bladder,  and  the  posterior  urethra.  The  cut-off  muscle  separates 
the  upper  from  the  lower  tract.  The  former  is  inside  the  body,  as  it 
were,  and  in  its  normal  state  entirely  aseptic.  The  lower  urinary  tract 
— i.e.,  the  anterior  urethra  of  the  male,  the  whole  urethra  of  the  female 
— is  in  no  way  separated  from  the  integument,  and  may  contain  the 
bacteria  that  flourish  upon  the  surrounding  parts. 

The  flora  of  the  anterior  urethra  have  already  been  described  in 
Chapter  XVI. 

Apart  from  prostatitis,  the  special  characteristics  of  which  have 
already  been  considered  (p.  163),  the  infections  of  the  upper  urinary 
tract  are: 

1.  Inflammation  of  the  bladder :   Cystitis,  pericystitis. 

2.  Inflammation  of  the  kidney,  its  pelvis,  and  the  ureter:  Acute 
renal  infection,  pyelonephritis,  infected  hydronephrosis,  pyonephrosis, 
perinephritis. 

3.  Certain  unusual  types  of  inflammation:  Incrustation,  malako- 
plakia,  leukoplakia,  cystitis  and  pyelitis  cystica  and  granulosa. 

Inasmuch  as  the  upper  urinary  tract  is  aseptic  when  in  its  normal 
condition,  the  three  prime  questions  to  be  answered  in  regard  to  inflam- 
mations are: 

1.  What  are  the  bacteria  of  urinary  infection? 

2.  How  do  they  obtain  access  to  the  urinary  tract? 

3.  Why  do  thece  bacteria  sometimes  cause  infection,  and  sometimes 
not? 

BACTERIA  OF  URINARY  INFECTION 

Since  the  gonococcus,  the  typhoid  bacillus,  and  the  tubercle  bacillus 
have,  for  obvious  reasons,  no  statistical  relation  to  the  other  bacteria 
causing  infection  of  the  urinary  organs,  and  since  they  cause  types  of 
infection  which  are  best  considered  separately,  they  are  not  included  in 
the  following  data. 

The  most  recent  study  of  the  bacteria  found  in  the  infected  urinary 

318 


BACTERIA  OF  URINARY  INFECTION  319 

organs  is  that  of  David.^     The  cultures  were  obtained  from  cases  of 
infection  of  various  parts  of  the  urinary  tract. 

Aerobes — 

23  bacillus  coli. 

15  staphylococcus  albus. 

3  staphylococcus  aureus. 

5  bacillus  enteritidis. 

3  bacillus  faecalis  alkaligenes. 


2  bacillus  proteus. 

2  bacillus  pyocyaneus. 

1  streptococcus. 

1  bacillus  pseudodiphtheriae. 

1  unidentified  Gram-positive  diplococcus. 

1  pneumococcus. 

1  influenza-like  bacillus. 

Anaerobes — 

4  black-pigment-producing  bacilli. 

4  Gram-negative,  influenza-like  bacilli. 

2  staphylococcus  parvulus. 

1  Gram-negative  coccus. 

1  bacillus  funduliformis. 

2  Gram-positive  staphylococcus. 

The  relation  of  the  anaerobic  bacteria  to  infection  has  not  yet  been 
determined.    We  shall  consider  only  the  aerobes. 

It  is  to  be  noted  that  various  bacteria  may  grow  simultaneously 
in  the  urinary  tract.  The  bacillus  coli  is  usually  a  part  of  such  mixed 
infections.  It  is  further  to  be  noted  that  certain  of  the  bacteria  sep- 
arately listed  in  the  above  table  may  be  grouped.  Among  the  fifty-eight 
listed  aerobes,  bacteria  of  the  colon  group  appear  thirty-one  times 
(53  per  cent),  staphylococci  eighteen  times  (31  per  cent),  while  the 
remaining  bacteria  may  be  classed  as  infrequent. 

Scheidemantel  ^  examined  100  cases  with  the  following  results :  89 
colon  gToup,  6  staphylococci,  3  proteus,  2  streptococcus,  2  influenza  bacil- 
lus, and  typhoid  bacillus,  a  diplococcus,  and  the  pyocyaneus,  each  once. 

This  represents  quite  closely  the  bacteria  found  in  infections  of  the 
renal  pelvis,  while  David's  list  represents  more  accurately  those  of  in- 
fections of  the  bladder  and  prostate.  In  other  words,  infections  of 
the  renal  pelvis  result  almost  ahuays  from  bacteria  of  the  colon  group, 
while  infections  of  the  bladder  are  much  more  frequently  due  to  the 
pyogenic  cocci. 

On  the  other  hand,  every  writer  who  has  reported  bacteriologic  in- 

^Surg.,  Gynec.  ^  Obstet.,  April,  1914,  xviii,  432. 
'Muench.  med.  Wochenschr.,  1913,  p.  1722,  1913. 


320  INFECTION  OF  THE  UPPER  URINARY  TRACT 

vestigation  on  perinephritis  has  noted  the  preponderance  of  the  pyogenic 
cocci  in  the  pus  obtained  from  perinephritic  abscess.  Though  the  num- 
ber of  cases  reported  by  any  one  observer  is  small,  the  universal  agree- 
ment on  the  preponderance  of  staphylococci  and  streptococci  in  causing 
perinephritic  suppuration  is  notable. 

Virulence. — The  available  data  do  not  suggest  any  particular  viru- 
lence attributable  to  any  specific  bacteria  or  strain  of  bacteria.  It  would 
seem  as  though  the  virulence  of  bacteria  depended  most  upon  the  acces- 
sory circumstances  under  which  the  infection  occurs.-^ 

Indeed  experiments  upon  animals  have  amply  proven  two  facts: 
In  the  first  place,  bacteria  may  be  presented  to  the  kidney  in  the  circu- 
lating blood,  pass  through  it  and  be  found  living  in  the  urine,  and 
yet  leave  behind  no  trace  of  their  passage.  In  the  second  place,  bac- 
teria may  be  injected  into  any  portion  of  the  normal  urinary  tract,  and 
cause  no  damage  whatsoever.  Clinical  observations  have  confirmed 
these  findings.  Thus  we  may  say  that  the  occurrence  of  infection 
depends  upon  the  simultaneous  presence  of  bacteria  and  some  accessory 
cause  of  infection. 

On  the  other  hand,  one  of  the  causes  of  intense  infection  is  the 
bacterial  splitting  up  of  urea  into  ammonia  and  water.  The  ammonia 
is  an  irritant,  and  causes  a  much  more  severe  infection  (ammoniacal 
infection)  than  occurs  when  the  urine  remains  acid.  The  chief  urea- 
splitting  microbes  are  the  proteus,  the  pyogenic  cocci,  and  sometimes 
the  typhoid  bacillus.  These  various  bacteria  show  a  marked  difference 
in  their  tendency  to  split  urea.  Sometimes  they  do  so,  sometimes 
they  do  not.  The  accessory  causes  of  infection  have  a  marked  influence 
in  encouraging  urea  splitting.  The  colon  group  of  bacteria,  with  an 
occasional  exception  of  typhoid  bacteria,  do  not  split  urea.  A  marked 
colon  infection  gives  to  the  urine  the  odor  of  a  dead  mouse,  but  does 
not  produce  ammonia. 

Crabtree  believes  that  acute  hematogenous  kidney  infection  due  to 
bacillus  coli  is  a  transitory  lesion  that  merely  lays  the  foundation  for 
chronic  pyelitis ;  while  suppurating  parenchymatous  lesions  are  always 
due  to  the  pyogenic  cocci. 


ROUTES  OF  INVASION 

Bacteria  reach  the  urinary  tract  through  four  routes: 

1.  The  descending  or  excretory  route. 

2.  The  ascending  or  urethral  route. 

^  This  statement  runs  counter  to  all  we  know  of  the  nature  of  infections.  Yet 
with  certain  limitations  it  is  true,  and  it  serves  to  focus  the  attention  of  the  practi- 
tioner upon  the  surgical  features  of  these  infections. 


ROUTES  OF  INVASION  321 

3.  The  lymphatic  route. 

4.  Direct  invasion  by  trauma  or  rupture  of  a  neighboring  abscess. 
The  Descending  or  Excretory  Route.— Without  stopping  to  debate 

the  question  whether  or  not  the  healthy  kidney  can  transmit  living 
bacteria  in  any  number  without  injury  to  its  secreting  structure,  w-e 
may  accept  as  clinically  proven,  notably  in  the  case  of  the  typhoid  bacil- 
lus, the  fact  that  living  bacteria  may  enter  the  urine  from  a  kidney 
clinically  sound.  There  is  strong  evidence  for  the  belief  that  in  the 
course  of  the  various  infectious  diseases,  even  in  tuberculosis,  bacteria 
may  be  transmitted  by  the  kidneys  without  leaving  any  appreciable  trace 
of  their  passage  through  those  organs. 

Inasmuch  as  it  seems  biologically  impossible  for  the  living  cell  to 
transmit  a  living  bacterium,  it  is  probable  that  normal  kidneys  trans- 
mitting healthy,  living  bacteria,  actually  suffer  a  temporary  localized 
inflammation  so  slight  as  to  escape  observation.  Crabtree's  ^  observa- 
tions certainly  seem  to  justify  the  theory  that  acute  descending  B.  coli 
infection  of  the  kidney,  sufficiently  intense  to  cause  symptoms  and  to 
produce  a  marked  temporary  diminution  of  phenolsulphonephthalein 
output,  may  disappear  so  completely  that  a  few  weeks  later  the  pathol- 
ogist is  unable  to  identify  any  lesions  in  the  kidney. 

Such  acute  temporary  infections  may  perhaps  occur  in  otherwise 
normal  kidneys  damaged  only  by  the  effort  to  excrete  a  large  number 
of  bacteria,  while  congested  by  the  toxins  of  these  very  bacteria  circu- 
lating in  the  blood.  Such  a  combination  v/ould  explain,  for  instance, 
the  fact  that  about  one  case  in  four  of  typhoid  fever  suffers  mild  renal 
infection.  Yet  no  relation  has  been  established  between  the  severity 
of  the  infectious  disease,  or  of  its  toxemia,  and  the  likelihood  of  renal 
infection  resulting  therefrom.  Hence  we  cannot  but  ask  ourselves 
whether  even  in  these  cases  the  one  infected  case  out  of  four  is  not 
perhaps  infected  because  of  some  local  cause  of  lessened  resistance  in 
the  kidney. 

On  the  other  hand,  we  must  admit  that  colon  infections  at  least  are 
almost  always  bilateral.  For  the  severe  acute  type  of  infection  we  can 
usually  find  a  mechanical  accessory  cause.  But  for  the  milder  infection 
of  the  opposite  kidney  we  usually  find  no  such  cause.  It  is  probable, 
therefore,  that  toxemia  and  massive  doses  of  bacteria  in  the  blood  are 
the  occasion  of  this  opposite  infection. 

In  order  to  explain  the  fact  that  pyogenic  cocci  are  relatively  com- 
mon in  perinephritic  abscess,  and  colon  bacilli  relatively  common  in 
infections  within  the  cavity  of  the  kidney,  Crabtree  has  evolved  the 
ingenious  theory  that  the  pyogenic  cocci  exhibit  in  the  kidney,  as  they 
do  elsewhere  in  the  body,  a  relative  tendency  to  immediate  pus  produc- 
tion of  considerable  intensity  as  compared  to  that  of  the  colon  group. 

*  Cf .  Cabot,  Trans.  Am.  Assn.  G.  U.  Surg.,  1916. 


322  INFECTION  OF  THE  UPPER  URINARY  TRACT 

Eeaching  the  kidney  through  the  circulation,  the  pyogenic  cocci  set 
up  their  infection  in  the  glomeruli,  i.  e.,  in  the  cortical  portions  of 
the  kidney;  whereas  the  colon  bacilli  are  more  likely  to  pass  through 
the  glomeruli,  and  to  attack  the  tubules.  Hence  colon  bacillus  infection 
extends  more  readily  to  the  pelvis  of  the  kidney,  coccus  infection  to 
the  perinephritic  tissue. 

The  sources  of  excretory  renal  infection  are  innumerable.  The 
bacteria  may  be  derived  from  focal  infection  (abscesses)  in  various 
parts  of  the  body,  or  catarrhal  infections  of  the  various  mucous  mem- 
branes. The  intestine  is  the  usual  source  of  bacillus  coli  infection, 
but  the  other  bacteria  are  derived  from  roots  of  teeth,  tonsils,  adenoids, 
furuncles,  accessory  nasal  sinuses,  appendicitis,  salpingitis,  etc. 

In  the  following  section  reasons  will  be  given  for  suspecting  that 
the  bladder,  the  prostate,  and  the  vagina  are  not  uncommon  sources 
of  descending  infection  in  clinical  conditions  that  have  heretofore  been 
considered  instances  of  ascending  infection. 

Urethral  or  Ascending  Invasion  of  the  Bladder. — The  three  methods 
by  which  microbes  may  ascend  from  the  urethra  to  the  bladder  are : 

1.  Through  instrumentation. 

2.  By  extension  upward  of  a  urethral  inflammation. 

3.  By  spontaneous  ascension  of  the  urethral  bacteria. 

1.  The  passage  of  an  instrument  into  a  clean  bladder  is  a  frequent 
cause  of  cystitis.  The  gentle  passage  of  a  smooth,  soft,  clean  instrument 
through  a  normal  canal  into  a  healthy  bladder  never  causes  cystitis. 
Perhaps  bacteria  are  carried  into  the  bladder  by  every  instrument. 
Perhaps  numerous  pathogenic  bacteria  are  introduced  in  this  manner. 
But  experiment  and  experience  unite  to  proclaim  that  the  healthy  blad- 
der is  thoroughly  able  to  sweep  itself  clean  of  these  enemies.  But  this 
is  not  enough.  The  bladder  may  be  thus  protected,  but  not  so  the 
posterior  urethra.  JSTot  to  mention  the  gonococcus,  any  of  the  bacteria 
enumerated  above  can  take  root  in  the  prostatic  portion  of  the  canal, 
if  only  the  soil  is  sufficiently  harrowed  to  receive  the  seed. 

Inasmuch  as  every  passage  of  an  instrument  into  the  posterior 
urethra  contuses  that  canal,  at  least  to  a  slight  degree,  it  is  impossible 
to  reproduce  clinically  the  laboratory  condition  under  which  bacteria 
may  be  safely  introduced  into  the  bladder.  Ascending  infection  of  the 
urinary  tract,  like  descending  infection,  requires  a  contributory  cause 
as  well  as  a  bacterium.  But  clinically  the  contributory  cause  is  ever 
present.  ISTo  passage  of  a  urethral  instrument  is  entirely  free  from 
trauma.  It  is,  therefore,  the  surgeon's  first  duty  to  see  to  it  that  his 
passage  of  urethral  instruments  be  as  cleanly  as  possible;  his  second 
duty,  as  important  as  the  first,  that  the  instrumentation  be  as  gentle  as 
possible. 

But  inasmuch  as  the  normal  anterior  urethra  cannot  be  made  wholly 


ROUTES  OF  INVASION  323 

aseptic,  while  the  bladder  into  which  the  urethral  instrument  passes, 
and  the  prostate  over  which  it  passes,  are  often  already  diseased  and 
contain  in  themselves  the  contributory  causes  of  infection  and  even 
(in  the  case  of  the  chronically  inflamed  prostate)  the  bacteria  them- 
selves, it  is  obvious  that  no  amount  of  cleanliness  or  of  gentleness  will 
protect  the  bladder  against  infection  when  instruments  have  repeatedly 
to  be  passed,  as,  for  instance,  in  the  treatment  of  prostatic  retention. 

2.  Infection  of  the  bladder  by  direct  extension  of  urethritis  occurs 
in  gonorrhea,  and  in  stricture ;  also  possibly  from  the  prostate  in  cases 
of  prostatic  retention.  Direct  extension  of  urethritis  to  the  trigone 
is  even  commoner  in  women  than  in  men. 

3.  Whether  the  bacteria  of  the  uninflamed  anterior  urethra  can 
ascend  to  the  bladder  against  the  urinary  stream  is  not  yet  definitely 
determined. 

Ascending  Infection  of  the  Kidney. — Innumerable  experiments 
have  repeatedly  proven  that  bacteria  do  not  ascend  from  the  bladder  to 
the  kidney  in  animals  unless  there  is  some  accessory  cause  of  infection. 
This  accessory  cause,  both  in  experiments  and  in  the  human  being,  is 
usually  some  form  of  retention  of  urine. 

The  routes  by  which  infection  may  conceivably  reach  the  kidney 
from  the  bladder  are  three: 

1.  Up  the  lumen  of  the  ureter. 

2.  Through  the  lymphatics  extending  along  the  ureter  from  the 
bladder  to  the  kidney  pelvis. 

3.  By  lymphatic  absorption  from  the  bladder  or  prostate  into  the 
general  circulation,  and  thence,  by  what  is  actually  a  descending  infec- 
tion, into  the  kidney  parenchyma. 

Evidence  has  been  accumulating  for  years  to  disprove  the  theory 
that  infection  can  travel  along  the  inside  of  the  ureter  from  bladder  to 
kidney.  This  evidence  has  been  summed  up  and  made  final  in  the 
observations  of  Sweet  and  Stuart.^  They  have  reviewed  the  evidence 
of  the  existence  of  a  network  of  lymph  vessels  in  the  mucosa,  and  sub- 
mucosa,  as  well  as  in  the  external  coats  of  the  bladder  and  ureters 
and  in  the  pelvis  of  the  kidney,  and  have  shown  that  this  network 
anastomoses  freely  throughout.  In  their  experiments  they  have  traced 
infection  up  these  lymphatics,  and  have  shown,  by  replacing  a  section 
of  the  ureter  with  a  tube  that  maintains  the  lumen  of  the  canal,  but 
interrupts  the  lymphatic  flow,  that  under  appropriate  circumstances 
bacteria  will  travel  up  to  the  opposite  kidney  whose  lymphatics  are 
intact,  but  not  up  to  the  kidney  whose  ureter  has  been  divided ;  al- 
though the  trauma  of  ureteral  division  should,  in  itself,  lower  the  re- 
sistance of  that  ureter. 

How  frequently  such  lymphatic  infections  of  the  kidney  occur  re- 
^  Surgery,  Gynecology  and  Obstetrics,  April,  3914,  xviii,  460. 


324  INFECTION  OP  THE  UPPER  URINARY  TRACT 

mains  an  open  question.  The  familiar  acute,  so-called  ascending  infec- 
tion, such  as  is  seen  in  postoperative  infection,  in  prostatic  retention  in- 
fections, in  urethral  chill,  and  in  defloration  pyelitis,  has  been  shown 
in  several  instances  to  be  associated  with  a  general  bacteremia,  while 
post  mortem  examination  fails  to  show  any  evidence  of  ascending 
lymphatic  infection  along  the  ureter. 

Crabtree  cites  a  case  in  point:  The  patient  entered  the  hospital 
for  the  treatment  of  a  prostatic  retention  of  urine.  A  catheter  was  tied 
in  the  urethra,  and  repeated  cultures  made  from  the  urine  obtained 
through  this  catheter  failed  to  show  any  bacterial  growth.  On  the 
seventh  day  the  patient  complained  of  some  uneasiness  in  the  peri- 
neum. A  blood  culture  was  promptly  made,  revealing  colon  bacillemia. 
Meanwhile  the  urine  still  remained  sterile.  Then  the  patient  had  a 
chill,  fever,  pain  in  the  loin,  and  a  sharp  fall  in  the  output  of  phenolsul- 
phonephthalein.  Blood  culture  was  now  negative,  but  culture  of  the 
urine  showed  bacillus  coli.  In  due  course  the  phenolsulphonephthalein 
output  returned  to  normal,  the  patient  submitted  to  perineal  pros- 
tatectomy, and  two  weeks  thereafter  died  of  streptococcus  septicemia. 
Post  mortem  examination  revealed  no  gross  evidence  of  renal  infection, 
or  of  lymphatic  infection  about  the  kidney  pelvis  and  ureter. 

Such  cases  force  us  to  the  conclusion  that  the  acute  phenomena 
of  kidney  infection  under  the  clinical  circumstances  enumerated  above, 
although  they  have  always  been  spoken  of  as  ascending  infections,  are 
actually  descending  infections  from  a  source  in  the  lower  urinary 
organs  (or  in  the  vagina  in  the  case  of  defloration  pyelitis). 

Thus  the  absence  of  any  positive  evidence  of  spontaneous  infection 
of  the  normal  bladder  from  the  normal  urethra,  or  of  the  kidney  from 
the  bladder,  leaves  the  theory  of  spontaneous  ascending  infection  "from 
the  short  urethra"  of  women  without  support.  If  this  does  occur,  we 
have  no  theory  whereby  it  can  be  explained. 

Direct  Lymphatic  Invasion. — The  possibility  of  direct  lymphatic 
infection  up  the  ureter  has  been  shown  by  Sweet  and  Stuart.  The 
possibility  of  direct  infection  of  the  right  kidney  from  its  lymphatic 
communication  with  the  hepatic  flexure  of  the  colon  has  been  shown 
by  Franke.^  It  is  also  possible  that  the  bladder  may  be  directly  in- 
fected by  lymphatic  invasion  from  the  rectum  or  the  vagina.  Finally, 
any  portion  of  the  urinary  tract  may  be  directly  infected  by  lymphatic 
absorption  from  an  adjacent  focus  of  suppuration. 

But  the  actual  frequency  of  infection  along  any  of  these  routes  is 
by  no  means  certain.  Future  investigators  will  have  to  determine  their 
clinical  importance. 

Infection  by  Eruption  and  Trauma — The  mechanism  by  which  in- 
fection reaches  the  urinary  channels  from  the  rupture  of  an  abscess  into 

^  Grenzgeb.  d.  Med.  u.  Chir.,  1911,  xxii,  623. 


ACCESSORY  CAUSES  OF  INFECTION  325 

them,  or  bj  trauma  directly  introducing  bacteria,  requires  no  special 
explanation.  But  it  is  not  to  be  forgotten  that  if  the  urinary  pas- 
sages are  otherwise  normal  even  the  discharge  into  them  of  pus  from 
a  suppurating  appendix,  an  intestinal  fistula  or  a  pyosalpinx  produces 
only  a  localized  infection. 


THE  ACCESSORY  CAUSES  OF  INFECTION  OF  THE  URINARY 

ORGANS 

The  mere  passage  of  pus  and  bacteria  through  a  normal  bladder 
discharging  from  an  infected  kidney  does  not  cause  cystitis.  The 
mere  presence  of  infection  in  the  bladder,  without  retention  of  urine, 
does  not  cause  infection  of  the  kidney.  The  mere  presence  of  bacteria  in 
the  blood  does  not  cause  infection  of  the  kidney.  Indeed,  when  the 
kidney  becomes  infected  in  the  course  of  a  pyemia,  the  characteristic 
result  is  the  bilateral  pyemic  kidney,  very  different  from  anything  we 
have  to  deal  with  in  surgery.  Such  clinical  observations  require  ex- 
planation. 

The  laboratory  suggests  the  explanation.  It  has  been  shown  again 
and  again  by  various  experimenters  that  the  normal  kidney  and  the 
normal  bladder  are  not  harmed  by  the  injections  into  their  cavities  of 
enormous  quantities  of  pathogenic  bacteria;  while  intravenous  injection 
of  bacteria  either  causes  the  bilateral  pyemic  kidney  or  apparently 
does  no  harm.  But  if  the  urethra  is  tied  off,  both  bladder  and  kidneys 
may  be  readily  infected.  If  one  ureter  is  tied  off,  or  one  kidney 
traumatized,  injection  of  the  bacteria  into  the  circulating  blood  results 
in  infection  of  that  kidney.  Manifestly,  therefore,  we  may  look  for 
the  cause  of  infection  of  the  urinary  organs  in  some  accessory  condition 
that  renders  the  organ  in  question  peculiarly  liable  to  infection.  Such 
a  condition  we  speak  of  as  the  accessory  cause  of  infection. 

We  should  consider  these  accessory  causes  of  infection  in  the  light 
of  recognized  clinical  conditions.  Some  of  these  clinical  conditions 
are  readily  explained,  e.  g.,  infection  due  to  retention,  stone,  or  trauma. 
Some  are  not  so  easily  explained,  e.  g.,  the  pyelonephritis  of  little 
girls.  Perhaps  the  best  test  of  any  general  theory  of  the  accessory  cause 
of  infection  in  obscure  cases  is  that  it  should  explain  why  the  right 
kidney  is  more  often  acutely  infected  than  the  left,  why  the  kidneys 
of  women  are  more  often  infected  than  those  of  men,  why  women 
are  so  commonly  infected  in  their  infancy.  In  other  words,  the  theory 
must  explain  the  infection  of  the  right  kidney  of  little  girls. 

The  accessory  causes  of  renal  infection  include  any  condition, 
whether  mechanical  or  toxic,  that  reduces  the  resistance  of  one  or  both 
kidneys  to  infection.     They  may  be  classified  as  follows : 


326  INFECTION  OF  THE  UPPER  URINARY  TRACT 

1.  Retention. 

a.  Urethral. 

b.  Ureteral. 

2.  Trauma. 

3.  Toxic  influences. 

4.  Reflex  influences. 

Retention. — ^Retention  of  urine,  whether  acute  or  chronic,  causes 
congestion  of  all  that  portion  of  the  urinary  tract  lying  above  the  point 
of  retention.  Thus  if  the  retention  is  in  the  urethra,  both  kidneys 
and  the  bladder  are  involved.  If  it  is  in  one  ureter  only,  one  kidney 
is  involved.  The  congestion  is  due  to  actual  pressure  of  urine.  Anyone 
who  has  seen  a  patient  writhing  in  the  agonies  of  acute  retention  of 
urine  will  not  doubt  its  existence  in  acute  cases.  The  congestion  of 
the  kidneys  in  chronic  retention  is  shown  by  the  reduction  in  the 
output  of  solids,  notably  of  phenolsulphonephthalein.  It  is  also  shown 
by  an  acute  congestion  at  the  time  of  relief  of  renal  retention,  sigiial- 
ized  by  a  marked  polyuria.  Albarran  was  the  first  to  note  that  the 
evacuation  of  an  intermittent  hydronephrosis  was  followed  by  a  period 
of  polyuria  from  that  kidney.  A  similar  polyuria  is  a  feature  of  grave 
prostatic  retention.  But  even  the  slightest  obstruction  is  quite  capable 
of  disturbing  the  normal  physiological  condition  of  bladder  and  kidneys. 
Thus  very  slight  obstructions  at  the  bladder  neck  may  cause  retention' 
of  urine,  stone  formation,  and  sometimes  undue  irritability  of  the 
bladder.  Similar  slight  and  unsuspected  obstructions  of  the  ureter  may 
cause  congestions  of  the  kidney,  which,  though  they  may  be  but  slight 
or  temporary,  may  happen  at  a  time  when  the  presence  of  bacteria  in 
the  blood  offers  the  occasion  for  renal  infection.  Crabtree's  case  cited 
above  is  a  very  good  example  of  how  temporary  even  an  acute  infection 
of  the  kidneys  may  be. 

If  we  are  to  find  in  the  theory  of  retention  a  cause  for  the  infection 
of  the  right  kidneys  of  little  girls,  we  must  seek  it  in  some  congenital 
condition.  Let  it  be  understood  that  the  following  theory  is  but  a 
theory.  Although  it  seems  at  the  present  moment  the  most  likely 
explanation  of  obscure  infection  of  the  kidney,  it  is  no  more  than  this. 
But  until  some  better  theory  supersedes  it,  we  may  take  the  liberty  of 
expounding  it  directly  as  though  it  were  an  established  fact,  since  this 
simplifies  the  exposition. 

Renal  mobility  is  discussed  in  Chapter  XLV.  Therein  will  be 
found  an  exposition  of  the  theory  of  Volkow  and  Delitzen,  which  pre- 
tends to  explain  by  a  study  of  the  anatomical  shape  of  the  niche  in 
which  the  kidney  lies  why  this  niche,  being  shallower  in  women  than 
in  men,  and  on  the  right  side  rather  than  on  the  left,  makes  the  right 
kidneys  of  women  more  liable  to  mobility  (as,  indeed,  we  clinically  know 
they  are)  than  their  left  kidneys  or  than  either  kidney  of  a  man.    It  is 


ACCESSORY  CAUSES  OF  INFECTION  327 

to  be  noted  further  that  in  many  instances  the  position  of  the  body 
determines  whether  the  kidney  shall  be  mobile  or  not,  and  that  children 
may  be  trained  to  hold  themselves  in  such  a  way  that  their  kidneys  shall 
not  become  mobile  when  they  reach  adult  life.  Thus,  although  what 
might  be  termed  the  gross  mobility  of  the  kidney  occurs  in  adolescence 
and  thereafter,  the  beginnings  of  this  mobility  are  congenital. 

N^ow  it  is  well  known  that  the  grossly  mobile  kidney  encourages 
inflammation,  and  does  so  by  virtue  of  kinking  of  the  ureter  whereby 
a  moderate  or  temporary  retention  occurs  in  the  kidney  which  may, 
under  exceptional  instances,  reach  an  intensity  shown  by  the  complete 
retention  of  Dietl's  crisis  or  of  intermittent  hydronephrosis. 

The  same  conditions  exist  to  a  lesser  degree  in  little  children.  But 
it  is  to  be  remembered  that  little  children  are  much  more  subject  to 
infections  of  all  sorts  than  adults.  Their  immunities  are  undeveloped 
by  contact  with  infection.  Doubtless  their  kidneys  share  this  lack  of 
immunity,  and  doubtless,  therefore,  the  kidneys  of  infants  are  more 
readily  infected  than  those  of  adults.  This  combination  of  unusual 
susceptibility  to  infection,  and  tendency  to  mobility,  explains,  we  be- 
lieve, the  infection  of  the  kidney  in  children,  and  more  particularly 
the  infection  of  the  right  kidney  in  little  girls. 

The  only  other  theory  that  has  been  seriously  advanced  to  explain 
this  condition  is  that  the  vagina  of  little  girls  is  often  infected  with 
colon  bacilli  from  the  rectum,  that  the  urethra  of  little  girls  is  short, 
that  they  often  have  incontinence  of  urine,  and  that  under  these  con- 
ditions the  bacillus  coli  readily  invades  the  bladder,  and  then  the 
kidneys.  But  all  our  experimental  evidence  points  to  the  fact  that 
no  infection  can  result  from  the  invasion,  either  of  the  bladder  or  of 
the  kidneys,  by  colon  bacilli  or  by  any  other  pathogenic  bacteria,  unless 
there  are  accessory  causes  of  infection  at  work.  Renal  mobility  is 
the  most  plausible  accessory  cause.  Whether  in  the  presence  of  renal 
mobility,  a  short  urethra,  or  an  infected  vagina,  or  incontinence  of 
urine  helps  to  infect  the  kidney  we  do  not  know.  It  seems  rather  more 
probable  that  the  infection  is  usually  derived  from  an  inflamed  colon. 

A  third  theory  of  infection  which  would  infect  the  right  kidney 
directly  from  the  lymphatic  connection  with  the  hepatic  flexure  of 
the  colon  would  be  difficult  either  to  prove  or  to  disprove.  But  since 
it  does  not  explain  the  frequency  of  this  condition  in  little  girls,  we 
may  neglect  it. 

Most  acute  infections  can  be  considered  in  terms  of  retention. 
Even  stone  and  tumor  often  excite  infection  not  less  as  foreign  bodies 
that  obstruct  the  outflow  of  urine  than  they  do  as  a  breeding  ground 
for  bacteria,  or  a  source  of  surface  irritation. 

Ureteral  obstruction  is  usually  unilateral.  It  may  be  due  to  ob- 
struction within  the  ureter  (e.  g.,  stone,  tumor,  blood  clot,  stricture), 


328  INFECTION  OF  THE  UPPER  URINARY  TRACT 

to  angulation  of  the  ureter  (e.  g.,  nephroptosis,  or  traction  by  tumors 
within  the  pelvis),  or  to  pressure  from  without  (e.  g.,  bj  the  pregnant 
uterus,  by  carcinoma,  by  appendical  or  other  abscesses,  etc.). 

Urethral  retention  causes  infection  of  bladder  and  both  kidneys. 
The  infection  may,  however,  be  mild  in  one  kidney,  acute  in  the  other. 
The  acute  infection  may  have  for  its  accessory  cause  only  the  urethral 
retention.  But  there  may  arise  a  secondary  ureteral  cause  of  reten- 
tion, such  as  a  kink.  In  order  to  relieve  such  renal  retention  it  is  neces- 
sary to  relieve  not  only  the  urethral  but  also  the  ureteral  obstruction. 

The  one  flaw  in  this  mechanical  theory  of  renal  infection  is  the 
infection  of  the  opposite  kidney.  Not  only  is  pyelonephritis  almost 
always  bilateral,  but  acute  infection  of  one  kidney  is  almost  always 
associated  with  mild  infection  of  its  fellow.  This  mild  infection  of 
the  opposite  kidney  is  doubtless  due  to  toxic  rather  than  to  retentative 
causes,  as  described  below. 

Trauma. — Trauma  includes  not  only  the  open  wound  and  the 
obvious  contusion,  but  also  the  trauma  of  stone,  the  trauma  of  slight 
wrenches  and  unnoted  bruises,  and,  above  all,  the  trauma  of  urethral 
instrumentation  which  is  so  large  a  cause  of  infection. 

Toxic  Influences — "We  may  note  in  passing  that  certain  renal  tox- 
emias do  not  appear  to  predispose  the  kidney  to  bacterial  infection. 
Bright's  disease,  whether  acute  or  chronic,  does  not  appear  to  make 
the  kidney  a  good  soil  for  bacterial  growth.  Tuberculosis  of  one  kidney 
often  produces  a  toxic  nephritis  in  its  fellow,  and  not  infrequently  this 
intoxicated  kidney  is  mildly  infected  with  bacillus  coli  or  the  pyogenic 
cocci.  But  I  have  never  seen  a  grave  infection  under  these  circum- 
stances. 

But,  as  suggested  in  the  preceding  section,  retention  is  not  by  any 
means  the  whole  story  in  the  accessory  causation  of  renal  infection. 
Thus  in  certain  instances  it  is  quite  obvious  that  the  hyperacute  renal 
infections  of  infants  are  due  to  abscesses  or  infections  elsewhere  in  the 
body  producing  a  grave  toxemia.  The  frequency  of  mild  renal  in- 
fection in  the  course  of  typhoid  fever,  and  the  readiness  with  which 
this  infection  gets  well,  both  show  that  the  intensity  of  the  toxemia  has 
much  to  do  with  causing  the  renal  congestion  that  causes  kidney  in- 
fection. The  preponderance  of  bilateral  bacillus  coli  infection  tells 
the  same  tale.  Yet  if  w^e  accept  the  doubtful  case  of  children  these  toxic 
influences  may  be  blamed  rather  for  mild,  chronic  bilateral  infections 
than  for  the  more  acute  ones  which  require  treatment.  Indeed,  it  is 
an  open  question  whether  acute  attacks  of  renal  infection  are  not  like 
acute  attacks  of  Bright's  disease,  mere  incidents  in  the  course  of  a 
chronic,  perhaps  unsuspected,  infection.  Be  that  as  it  may,  acute 
infection  is  apparently  due  rather  to  mechanical  causes,  chronic  in- 
fection often  to  toxic  ones. 


SUMMARY  329 

Reflex  Influences. — Mild  infection  of  a  kidney  opposite  to  an 
acntely  infected  kidney  might  be  set  down  to  reflex  influences  in  the 
sense  that  that  opposite  kidney  is  called  upon  to  do  extra  work  through 
the  disease  of  its  fellow,  and  to  become  obviously  congested  and  en- 
larged if  its  fellow  is  chronically  debilitated  as  well  as  acutely  dis- 
eased. 

The  prostatorenal  reflex  is,  however,  of  far  more  importance. 
Urethral  chill,  though  it  follow  the  passage  of  instruments  into  the 
urethra,  is  actually  the  expression  of  an  acute  infection  of  the  kidney. 
Between  the  time  of  the  passage  of  the  instrument  and  that  of  the 
occurrence  of  the  chill,  a  general  bacteriemia  develops.  Urethral  chill 
probably  never  occurs  unless  the  kidney  has  been  previously  damaged 
by  chronic  infection  or  by  retention. 

We  may  once  again  cite  Crabtree's  classical  case  as  tracing  the 
course  of  the  bacteria  from  the  blood  through  the  inflamed  kidneys  into 
the  urine. 

Defloration  pyelitis  is  doubtless  only  a  form  of  urethral  chill.  There 
is  good  reason  to  believe  that  many  women,  who  have  had  acutely  in- 
fected kidneys  in  their  infancy,  continue  to  harbor  a  latent  colon 
bacillus  infection  in  the  pelvis  of  the  kidney,  and  that  this  is  the 
occasion  of  the  acute  outbreak  at  the  time  of  the  rupture  and  infection 
of  the  hymen. 

SUMMARY 

Apart  from  the  tubercle  bacillus,  the  important  infecting  micro- 
organisms of  the  urinary  tract  may  be  divided  into  two  groups.  On 
the  one  hand,  the  colon  group  causing  90  per  cent  of  the  infections  of 
the  pelvis  of  the  kidney.  On  the  other  hand,  the  pyogenic  cocci  which 
predominate  in  perinephritic  abscess  and  divide  with  the  colon  group 
the  etiology  of  infections  of  the  bladder. 

Mixed  infections  are  common. 

The  commonest  mode  of  infection  is  by  an  initial  inflammation 
of  the  kidney  parenchyma  through  bacteria  derived  from  the  blood 
stream. 

Ascending  infection  from  the  bladder  to  the  kidney  does  not  ascend 
as  a  surface  infection  along  the  ureter.  It  may  occur  along  the  lymphat- 
ics of  the  ureter.  It  probably  occurs  with  great  frequency  by  ab- 
sorption from  the  prostate  or  bladder  into  the  general  circulation,  and 
re-excretion  of  bacteria  through  the  kidney.  It  is,  therefore,  actually 
a  descending  infection. 

The  presence  of  bacteria  in  the  circulating  blood  does  not  entail  a 
renal  infection. 

Bilateral  renal  infection  is  doubtless  often  due  to  a  toxi.c  accessory 


330  INFECTION  OF  THE  UPPER  URINARY  TRACT 

cause.     Unilateral  infection  is  usnallj  due  to  a  meclianical  accessory 
cause,  and  this  is  most  frequently  some  form  of  retention. 

The  accessory  causes,  more  than  any  other  factor,  determine  the 
acuteness  of  the  infection  and  its  pathological  development. 


CHAPTEE   XXXIV 
PATHOLOGY  OF  RENAL  INFECTION 

The  phenomena  of  renal  infection  are  due  to  a  common  bacterial 
cause.  But  clinically  they  present  the  widest  variety,  both  in  intensity 
and  in  duration.  ISTo  contrast  could  be  greater  than  that  between 
microscopic  bacteriuria  and  a  hyperacute  focal  suppurative  nephritis. 
Yet  the  one  may,  under  appropriate  circumstances,  be  transformed  into 
the  other.^ 

We  are  obliged  to  consider  the  lesions  of  pelvis  and  parenchyma 
separately.  Indeed,  in  the  preceding  chapter  we  have  spoken  of  in- 
fection reaching  the  kidney  parenchyma  first  and  then  the  pelvis.  Yet 
clinically  speaking  inflammation  of  the  pelvis  of  the  kidney  means 
inflammation  of  its  ureter,  and  of  the  kidney  parenchyma  as  well; 
while  inflammation  of  the  kidney  parenchyma  without  some  inflamma- 
tion of  the  kidney  pelvis  is  the  rarest  of  exceptions.  Thus  the  lesions 
described  below  form  only  the  various  parts  and  phases  of  a  single 
picture  of  what  we  know  as  renal  infection. 

The  lesions  of  renal  infection  may  be  classified  as  follows : 

1.  Acute  suppuration  of  the  kidney. 

a.  The  pyemic  kidney. 

b.  Focal  suppurative  nephritis. 

2.  Acute  pyelitis. 

3.  Chronic  pyelonephritis. 

4.  Pyonephrosis. 

5.  Infected  hydronephrosis. 

6.  Perinephritis. 

a.  Fibrolipomatous. 

b.  Suppurative. 

7.  Rare  inflammatory  conditions  of  the  renal  pelvis. 

a.  Pyelitis  granulosa. 

b.  Malakoplakia. 

c.  Pyelitis  cystica. 

d.  Leukoplakia, 
6.  Incrustation. 

*  Recent  observations  by  Crabtree  (Cabot,  Trans.  Am.  Assn.  G.-U.  S%ir(].,  1916) 
tend  to  dissociate  more  clearly  than  ever  before  the  acute  lesions  of  the  renal  paren- 
chyma (due  to  pyogenic  cocci)  from  those  of  the  pelvis  (due  to  bacillus  coli). 

331 


332 


PATHOLOGY  OF  RENAL  INFECTION 


ACUTE   SUPPURATION   OF   THE   KIDNEY 


The  Pyemic  Kidney. — By  the  pyemic  kidney  we  understand  a  con- 
dition of  multiple  suppurating  points  in  both  kidneys.  The  abscesses 
are  chiefly  in  the  cortex.  The  renal  lesion  is  only  part  of  a  general 
pyemia.  Consequently  the  patient  dies  before  the  lesions  are  far  ad- 
vanced or  have  ruptured  into  the  perinephritic  space  or  into  the  kidney 


Fig.  67. — Focal  Suppurative  Nephritis.     The  kidney  is  split  and  seen  from  without. 
It  is  mottled  by  groups  of  miliary  abscesses.     Vessels  and  ureter  in  center. 

pelvis.  The  lesions  manifest  themselves  only  by  interference  with  the 
kidney  function ;  the  diagnosis  is  made  post  mortem ;  the  condition  has 
no  clinical  interest. 

Focal  Suppurative  Nephritis. — The  acute  bacterial  infections  of 
the  kidney,  though  they  vary  in  importance  from  a  brief  urethral 
chill  to  the  rapidly  fatal  condition  which  Brewer  has  made  familiar 
under  the  name  of-  unilateral  septic  infarcts  of  the  kidney  ^  may  all 
be  grouped  under  the  title  "Focal  Suppurative  Nephritis." 

The  milder  lesions  consist  of  little  more  than  an  acute  degeneration 
^ISurg.  Gyn.  and  Obst.,  May,  1906;  J.  A.  M.  A.,  .Tuly  15,  1911. 


PLATE    XI 


Fig.   1 


Fig.  2 


Focal  Suppurative  Nephritis. 

Fig.  1. — Acute  Stage.     The  pelvis  is  congested  and  ecchymotic.     There  are  streaks  of  pus 

showing  the  lines  of  lymphatic  absorption.     Also  a  large  "infarct." 
Fig.  2. — Neglected  Case.     The  kidney  is  a  multilocular  abscess. 


ACUTE  PYELITIS  333 

and  congestion  of  tlie  whole  kidney  parenchyma.  With  this  or  any  of 
the  more  acute  lesions  there  may  be  associated  an  acute  pyelitis. 

A  more  intense  degree  of  inflammation  of  the  kidney  parenchyma 
shows  itself  in  the  production  of  areas  of  localized  necrosis  and  suppura- 
tion in  various  portions  of  the  cortex  and  pyramids.  If  the  infection 
is  due  to  colon  bacillus  these  lesions  are  chiefly  in  the  medulla,  near 
the  pelvis.  But  from  these  initial  foci  of  suppuration  lymphatic  ab- 
sorption takes  place  radiating  through  the  parenchyma  of  the  kidney 
toward  the  capsule,  with  the  formation  of  secondary  areas  of  necrosis 
and  suppuration  here  and  there  in  the  course  of  this  lymphatic  ab- 
sorption. Thus  are  formed  the  characteristic  wedge-shaped  lesions  of 
acute  suppuration  and  degeneration  so  characteristic  of  focal  suppura- 
tive nephritis,  to  which  the  name  septic  infarcts  is  given.  This  title 
is  a  misleading  one.  The  lesions  in  many  instances  are  perfectly  well 
known  not  to  be  infarcts.  Thus,  for  example,  they  frequently  occur 
in  a  chronically  inflamed  kidney  after  the  removal  of  a  stone  from 
the  pelvis.  In  such  a  case  there  can  be  no  question  of  actual  infarcts. 
With  these  colon  bacillus  lesions  of  the  parenchyma  there  is  always 
associated  a  pyelitis,  acute  or  chronic  (Fig.  67;  PI.  XI). 

If  still  further  neglected  these  suppurating  points  may  resolve  or 
may  discharge  into  the  kidney  pelvis  (in  which  case  the  patient  may 
spontaneously  recover)  or  into  the  perinephritic  tissue  (in  which  case 
operation  is  usually  necessary  to  a  cure).  In  other  cases  the  sup- 
puration continues  within  the  kidney  parenchyma  until  finally  the 
patient  dies  of  septicemia  or  pyemia. 

The  more  acute  cases  that  come  to  operation  show  a  large  con- 
gested kidney  with  multiple  small  abscesses  under  the  capsule,  or 
perinephritic  abscess,  or  simply  irregularly  distributed  patches  dis- 
tinctly projecting  beneath  the  capsule,  and  darker  in  color  than  the 
surrounding  parenchyma.  On  section  these  irregular  areas  are  found  to 
])e  the  bases  of  the  pyramidal  patches  of  lymphatic  absorption  from 
medullary  abscesses. 

ACUTE  PYELITIS 

I  have  seen  but  two  instances  of  this  lesion:  One  not  due  to  re- 
tention showed  a  generally  swollen  bright  red  interior  to  the  kidney 
pelvis.  The  other,  due  to  ureteral  stone,  showed  a  blotchy  petechial 
condition,  microscopic  examination  of  which  revealed  acute  inflamma- 
tion and  degeneration. 

A  more  intense  form  of  pyelitis  is  sometimes  seen  as  the  result  of 
acute  obstructio.n  of  the  ureter  by  stone.  In  such  cases  the  combina- 
tion of  intense  distention  with  acute  infection  causes  gangrene  of  the 
ureter,  comparable  to  that  so  commonly  seen  in  virulent  infections  of 


334  PATHOLOGY  OF  RENAL  INFECTION 

the  appendix.     Curiously  enough  the  kidney  above  such  a  ureter  and 
kidney  pelvis  may  show  only  an  acute  congestion. 


CHRONIC  PYELONEPHRITIS 

The  mildest  type  of  chronic  renal  infection,  renal  hacteriuria,  pro- 
duces lesions  so  slight  that  they  have  not  been  precisely  identified. 
Crabtree  believes  the  foci  of  chronic  infection  lie  just  beneath  the 
mucosa  of  the  pelvis  of  the  kidney,  about  the  calices. 

More  severe  cases  of  long  duration  exhibit  a  kidney  adherent  in 
more  or  less  fibrolipomatous  perinephritis.  The  organ  itself  may  be 
not  far  from  normal  in  size,  but  the  pelvis  and  ureter  are  likely  to  be 
thickened,  dilated,  and  also  surrounded  by  adherent  sclerotic  fat.  This 
moderate  dilatation  of  the  kidney  pelvis  and  ureter  occurs  independently 
of  any  recognizable  ureteral  obstruction.-^  On  section  the  kidney  mark- 
ings are  lost,  its  tissue  rather  pale  and  fibrous  in  character,  the  cortex 
thin,  the  papillae  flattened  in  the  dilated  calyces.  The  surface  of  the 
pelvis  and  ureter  may  show  a  glazed  or  granulating  appearance  or  may 
manifest  any  of  the  unusual  changes  to  be  later  described. 

The  microscope  reveals  destruction  of  the  kidney  parenchyma  by 
sclerosis,  pyogenic  infiltration,  and  degeneration.  Similar  microscopic 
lesions  are  found  in  the  kidney  pelvis  and  ureter. 

The  ultimate  outcome  of  this  chronic  sclerosis  is  to  leave  the  kidney 
little  more  than  a  pyonephrotic  shell. 

Stone  is  a  common  cause  and  complication  of  pyelonephritis. 


PYONEPHROSIS 

Pyonephrosis  is  a  term  somewhat  loosely  applied  to  cover  two 
differing  conditions. 

One  of  these  is  the  relatively  acute  condition  developing  as  the 
result  of  retention  combined  with  infection.  The  retention  causes 
dilatation  of  the  kidney;  the  infection,  while  not  sufficiently  acute  to 
cause  any  very  marked  acute  renal  parenchymatous  changes,  usually 
produces  a  relatively  thick  pus  within  the  kidney  pelvis,  and  a  rela- 
tively rapid  sclerosis  of  the  kidney  parenchyma.  If  such  a  case  is 
operated  upon  early,  the  kidney  is  found  imbedded  in  a  thick  ede- 
matous mass  of  perirenal  fibrolipoma.  The  organ  itself  is  much  dis- 
tended. The  ureter  as  a  result  of  dilatation,  thickening  of  its  walls, 
and  perirenal  adhesive  inflammation,  may  be  as  big  round  as  the  finger. 
On  section  thick  pus  flows  from  the  dilated  renal  pelvis,  the  renal 

^Pyelography  often  gives  a  picture  quite  like  that  shown  in  Fig.  82. 


PERINEPHRITIS 


335 


parenchyma  shows  marked  lesions  of  chronic  pyelonephritis,  perhaps 
interspersed  with  foci  of  acute  infection. 

The  other,  or  chronic  type  of  pyonephrosis,  is  the  result  either  of 
a  mild  infection  in  a  dilated  kidney  or  simply  the  end  phase  of  severe 
chronic  pyelonephritis.  In  snch  cases,  though  the  renal  pelvis  be 
considerably  dilated,  the  pa- 
renchyma is  so  much  shrunk- 
en that  the  total  mass  of  kid- 
ney may  be  actually  smaller 
than  the  normal;  usually, 
however,  it  is  much  larger 
than  normal,  and  may  attain 
enormous  size.  The  dilated 
pelvis  is  often  only  a  scar  in 
which  it  is  impossible  to  dis- 
tinguish where  pelvis  ends 
and  kidney  begins.  The  fi- 
brolipomatous perinephritis 
assumes  enormous  propor- 
tions, so  that  the  kidney  lies 
embedded  in  a  dense  fatty 
capsule  which  may  be  several 
centimeters    thick.      Indeed, 

021  section  it  may  b3  found  that  the  very  renal  parenchpna  itself  has 
been  replaced  by  fat,  so  that  in  the  most  extreme  cases  of  this  type  the 
kidney  pelvis  is  capped,  not  by  renal  parenchyma,  but  by  its  semblance 
in  lobules  of  dense  yellow  fat. 


Fig. 


68. — Pyonephrosis.     The  kidney  is  reduced 
to  a  multilocular  suppurating  cavity. 


INFECTED    HYDRONEPHROSIS 

The  infective  lesions  are  those  of  pyelonephritis,  the  essential  lesion 
that  of  hydronephrosis  (p.  458). 


PERINEPHRITIS 


Fibrolipomatous  Perinephritis. — Fibrolipomatous  perinephritis  i? 
the  aseptic  reaction  of  the  perinephritis  tissue  to  the  lymphatic  dis 
tribution  of  toxins  from  bacterial  processes  within  the  kidney.  The 
earliest  reaction  found  upon  operation  upon  acute  cases  of  renal  in- 
fection is  edema  of  the  fibrofatty  envelope.  As  the  process  becomes 
chronic,  this  edema  is  replaced  by  scar,  binding  the  perirenal  tissues 
to  the  fibrous  capsule  of  the  kidney,  and  enveloping  masses  of  dense 


336 


PATHOLOGY  OF  RENAL  INFECTION 


yellow  fat,  yery  different  from  the  nonnal  soft,  white  perirenal  fat. 
This  protective  perinephritic  reaction  has  little  clinical  interest,  ex- 
cepting insomuch  as  it  markedly  increases  the  difficulties  in  nephrec- 
tomy for  old  renal  infection.  In  ancient  cases  it  envelopes  in  a  thick 
mass  the  kidney,  the  pelvis,  the  ureter,  and  the  pedicle,  and  in  some 
instances  it  even  replaces  the  kidney  tissue  itself,  so  that  the  line  of  de- 
marcation between  kidney  and  perirenal  fibrolipoma  is  but  a  thin  line 
of  scar,  which  is  all  that  remains  of  the  kidney  capsule. 


Fig.  69. — Perinephritis  (Morris).  Dense  fibrolipomatous  perinephritis  due  to  intrarenal 
suppuration.  The  probe  shows  a  fistula,  through  which  the  suppuration  has  extended 
to  the  perirenal  tissue  in  spite  of  the  protective  inflammation. 

Suppurative  Perinephritis. — Although  clinically  the  distinction  can- 
not always  be  made,  we  must  recognize  the  pathological  difference  be- 
tween true  perinephritic  abscess,  i.  e.,  suppuration  within  the  fascial 
capsule  of  the  kidney,  and  false  perinephritic  abscess  occupying  the 
retroperitoneal  fat,  but  originating  outside  of  the  perinephritic  fascia, 
and  more  properly  termed  subdiaphragmatic  or  paranephritic  abscess. 
True  perinephritic  abscess  probably  always  arises  from  some  lesion  of 
the  kidney  cortex;  though  in  many  instances  this  lesion  is  not  dis- 
covered. False  perinephritic,  or  subdiaphrag-matic,  abscess  is  due  to 
suppuration  in  the  surrounding  viscera  or  parietes. 

As   already   stated,   the   pyogenic   cocci    predominate    in   the  pus. 


RARE  INFLAMMATORY  CONDITIONS  337 

Thus  Miller^  found  staphylococci  iu  twelve  cases,  streptococci  iii  two, 
streptococci  and  pneumococci  in  one,  bacillus  coli  in  six  (two  were 
sterile).  Not  counting  the  sterile  cases,  this  series  shows  71  per  cent 
of  pyogenic  cocci  as  against  24  per  cent  bacillus  coli ;  quite  the  reverse 
to  the  statistics  for  pyelonephritis. 

The  perirenal  fascial  envelope  usually  permits  the  suppuration 
within  it  to  extend  only  through  its  open  lower  end.  Thence  it  passes 
forward  over  the  ileum,  and  even  into  the  true  pelvis.  If  neglected  it 
may  burst  into  the  intestine,  or  the  bladder,  or  through  the  skin,  or  it 
may  even  pass  upward  through  the  fascial  envelope  and  rupture  into  the 
pleura  or  lung. 


RARE  INFLAMMATORY  CONDITIONS  OF  THE  RENAL  PELVIS 

The  following  conditions  may  all  occur  in  the  pelvis,  the  ureter, 
or  the  urinary  bladder,  though  they  are  likely  to  be  chiefly,  or  even 
exclusively,  confined  to  one  or  the  other  extremity  of  the  urinary 
reservoir.  All  of  them  are  rare;  all  of  them  appear  to  have  some  rela- 
tion to  chronic  bacterial  infection  and  inflammation  of  the  pelvis  and 
bladder. 

Pyelitis  Granulosa. ^ — Pyelitis  gTanulosa  or  follicularis  is  a  lym- 
phoid infiltration  of  the  mucous  membrane  of  the  kidney  pelvis.  It  is 
apparently  the  result  of  chronic  pyelitis,  though  it  is  said  to  have  been 
found  post  mortem  in  uninfected  cases.  The  pelvis  presents  a  rough  and 
pebbled  gross  appearance.  The  microscope  reveals  little  aggregations 
of  lymphoid  tissue  in  the  mucosa.  They  are  vascular,  and  show  a  tend- 
ency to  capsule  formation.  The  larger  ones  may  ulcerate.  They  usually 
produce  no  symptoms.     They  may  bleed  or  deliver  pus. 

Malakoplakia.^ — This  consists  in  grayish  or  yellowish  nodules  made 
up  of  large  cells  (20/x  in  diameter),  containing  colon  bacilli,  leuko- 
cytes and  peculiar  cell  inclusions.  These  nodules  may  be  found  in  the 
renal  parenchyma  as  well  as  on  the  mucous  membrane  of  the  urinary 
reservoir. 

Pyelitis  Cystica — This  condition,  like  the  preceding  two,  is  usually 
associated  with  chronic  inflammation.  It  is  commoner  in  the  bladder 
than  in  the  pelvis  of  the  kidney.  The  lesions  are  usually  multiple,  and 
vary  from  small  red  elevations  on  the  mucous  membrane  that  look 
precisely  like  pyelitis  granulosa,  to  larger  bodies  that  wlion  seen  tli rough 
the  cystoscope  in  the  bladder,  for  instance,  or  observed  iu  the  kidney 
pelvis  post  mortem,  look  distinctly  cystic.     The  cysts  apparently  never 

^Annals  of  Surg.,  March,  1910. 

'Kretschmer,  Surg.,  Gyn.  ^-  Obstet.,  lOlP,,  xvii,  612. 

''MacDonald  and  Sewell,  Jour.  Path,  (f  Boot.,  1914,  xviii,  ,306. 


338  PATHOLOGY  OF  RENAL  INFECTION 

attain  a  very  great  size.  Under  the  microscope  the  lesion  looks  very 
much  like  a  papilloma,  with  the  difference  that  the  true  neoplasm 
springs  from  the  surface  of  the  mucous  membrane,  and  projects  above 
it,  while  cystitis  cystica  is,  as  it  were,  inverted,  and  digs  under  the 
epithelial  surface  of  the  mucosa.  The  larger  lesions  are  frankly  cystic 
(Figs.  68  and  108). 

Leukoplakia.^ — Leukoplakia  occurs  much  more  rarely  in  the  blad- 
der than  on  the  tongue,  much  more  rarely  in  the  kidney  pelvis  than  in 
the  bladder.  'No  relation  has  been  established  between  urinary  leuko- 
plakia and  syphilis.  Published  reports  do  not  suggest  any  tendency 
to  malignancy,  although  leukoplakia  of  the  urethra  is  a  distinctly 
malignant  condition.  I  have  seen  two  cases  of  leukoplakia  in  the  blad- 
der, the  lesions  occupying  the  fundus,  and  the  regions  back  of  the 
ureter  mouth.  I  have  never  seen  leukoplakia  of  the  kidney  pelvis. 
The  bladder  lesions  resemble  those  seen  upon  the  tongue,  a  whitish, 
thick,  epithelial,  flat  surface  with  a  reddish  border,  while  here  and 
there  in  the  vicinity  are  seen  reddish  lesions  of  chronic  inflammation 
upon  which  the  squamous  epithelium  has  not  yet  collected  in  sufficient 
quantities  to  give  them  the  white  color. 

Calculous  Incrustations.- — Phosphatic  incrustation  upon  an  ulcera- 
tive inflammatory  lesion  is  always  due  to  ammoniogenic  bacteria,  usu- 
ally the  pyogenic  cocci  or  the  proteus.  Phosphatic  incrustations  are 
also  seen  on  the  renal  lesions  of  tuberculosis.  Indeed,  this  is  the 
commonest  form  of  incrustation  in  the  kidney  pelvis.  Bladder  incrus- 
tation is  usually  the  result  of  the  infection  following  upon  the  establish- 
ment of  a  permanent  suprapubic  fistula,  but  it  also  occurs  in  connection 
with  phosphatic  stone,  tumor  and  even  in  cases  of  chronic  pyelitis  and 
cystitis.  Incrustation  and  ulcer  alike  are  the  expressions  of  the  reac- 
tion of  the  mucosa  to  a  virulent  ammoniogenic  inflammation. 

^  Beer,  Am.  Jour.  Med.  Sci.,  1914,  cxlvii,  244.  Lecene,  Jour.  d'Urol.,  1913,  iii, 
129. 

^  Caulk.,  Trans.  Am.  Assn.  G.-TJ.  Surg.,  1914. 


CHAPTER    XXXV 
THE  CLINICAL  PICTURE  OF  RENAL  INFECTION 

Infection  of  the  kidney  often  first  shows  itself  by  an  acute  febrile 
attack.  This  may  be  so  mild  as  to  escape  diagnosis  or  so  severe  as  to 
prove  fatal  within  a  few  days.  Usually  it  subsides  in  time,  however, 
leaving  the  patient  with  chronic  pyelonephritis.  This  in  turn  may  be 
so  mild  as  to  be  to  all  intents  and  purposes  harmless,  or  if  complicated 
by  retention,  stone,  trauma,  etc.,  its  course  may  be  interrupted  by  out- 
breaks of  acute  infection,  and  it  terminates  in  pyonephrosis. 

Certain  of  the  lesions  described  in  the  preceding  chapter  do  not 
interest  us  as  clinicians.  Thus  the  pyemic  kidney  kills  without  symp- 
toms worthy  of  the  name,  and  the  various  rare  lesions  of  the  renal 
pelvis  are  rather  pathological  curiosities  than  clinical  entities. 

ACUTE  RENAL  INFECTION 

Under  this  title  we  may  group  the  lesions  variously  described  as 
acute  pyelitis,  acute  pyelonephritis,  focal  suppurative  nephritis,  uni- 
lateral septic  infarcts,  etc.,  for  these  are  but  milder  or  severer  examples 
of  a  single  pathological  process. 

The  one  common  symptom  of  all  these  conditions  is  fever.  The 
cases  may.be  classified  as  mild,  severe,  and  fulminating. 

Mild  Cases. — The  only  subjective  symptom  is  a  rise  of  temperature. 
If  the  renal  infection  is  due  to  the  pyogenic  cocci,  and  occurs  in  the 
course  of  a  sepsis,  no  pus  may  appear  in  the  urine,  and  the 
renal  involvement  may  evade  diagnosis  unless  it  leads  to  perinephritic 
abscess.  Such  infections  may  be  diagnosed  with  a  reasonable  degree 
of  certainty  by  loin  tenderness  combined  with  the  finding  of  pyogenic 
cocci  in  the  urine  obtained  by  ureter  catheter  from  the  kidney,  and 
also  by  the  lowering  of  the  phenolsulphonephthalein  and  urea  output.^ 
Mild  infection  of  the  colon  or  pyelitic  type  may  be  due  to  coccus  in- 
fection. 

Mild  renal  infection  due  to  colon  bacillus  is  much  more  common. 

*  I  saw  Dr.  Beer  operate  upon  a  small  staphylococcus  perinephritic  abscess  due 
to  a  single  focus  of  renal  infection.  Yet  the  urine  from  this  kidney  had  shown  no 
diminution  of  function,  no  pus,  no  bacteria  by  culture. 

339 


340  CLINICAL  PICTURE  OF  RENAL  INFECTION 

It  is  characterized  by  fever  of  an  irregular  type,  and  the  appearance 
of  pus  and  colon  bacilli  in  the  urine.  The  phenolsulphonephthalein  and 
urea  output  are  lowered.  There  may  or  may  not  be  pain  and  tender- 
ness in  the  loins.  In  certain  cases  the  clinical  picture  is  dominated  by 
frequent  and  painful  urination.  This  symptom  is  purely  reflex,  and 
does  not  indicate  the  presence  of  inflammation  of  the  bladder  (p.  343). 

In  other  cases  digestive  symptoms  predominate.  This  type  of  case 
is  especially  misleading  in  infancy  when  a  clean  specimen  of  urine  is 
so  hard  to  obtain.  But  a  study  of  the  urine  for  pus  and  bacteria,  and 
impairment  of  the  renal  function  establishes  the  diagnosis. 

The  course  of  these  cases  is  most  irregular.  They  may  drag  along 
quite  indefinitely,  or  through  the  intervention  of  some  accessory  cause 
they  may  at  any  time  become  more  severe.  Under  appropriate  treat- 
ment they  usually  subside  into  chronic  pyelonephritis. 

Severe  Cases. — Severe  acute  renal  infection  is  but  an  intensifica- 
tion of  the  mild  acute  infection  described  in  the  preceding  paragraphs. 
The  attack  usually  begins  with  a  chill,  and  proceeds  with  an  irregular 
septic  temperature,  leukocytosis,  impairment  of  renal  function,  and 
pus,  albumin  and  bacteria  in  the  urine. 

The  dominating  feature  of  the  clinical  picture  (apart  from  the 
fever)  is  pain  and  tenderness  in  the  loin.  The  pain  is  usually  so  severe 
that  the  patient  complains  of  it,  the  tenderness  in  the  kidney  may  be 
elicited  by  ballottement,  even  when  the  kidney  itself  is  impalpable. 
As  a  rule,  however,  the  kidney  is  palpably  enlarged,  as  well  as  sensi- 
tive. 

Tenderness  of  the  kidney  means  tension  upon  its  capsule.  Apart 
from  such  obvious  causes  of  tension,  as  trauma,  acute  retention,  etc., 
renal  tenderness  is  almost  pathognomonic  of  infection.  Compensa- 
tory hypertrophy  constitutes  the  one  misleading  exception.  Since  com- 
pensatory hypertrophy  is  often  due  to  inflammatory  destruction  of  the 
opposite  kidney  the  exception  is  manifestly  an  important  one. 

Fulminating'  Cases — In  the  most  severe  cases,  however,  the  intense 
sepsis  overshadows  all  other  symptoms.  The  kidney  is  exquisitely 
sensitive  to  pressure,  but  the  pain  is  felt  rather  as  a  general  sensitive- 
ness of  the  upper  abdomen  than  as  a  pain  in  the  loin.  Such  truly  fulmi- 
nating attacks  are  likely  to  be  mistaken  for  some  form  of  peritoneal 
sepsis  (due  to  appendicitis  or  cholecystitis).  They  are  readily  differ- 
entiated by  the  exquisite  kidney  tenderness.  The  fulminating  case  is 
often  due  to  staphylococcus.  The  ureter  catheter  specimen  may  show 
only  red  blood  cells  and  bacteria  as  evidence  of  disease. 

Immediate  nephrectomy  is  required  to  save  the  patient's  life. 


CHRONIC  PYELONEPHRITIS  341 


CHRONIC  PYELONEPHRITIS 

Chronic  pyelonephritis  usually  begins  with  an  acute  febrile  attack, 
though  this  may  be  so  mild  as  to  be  overlooked.  It  continues  under  one 
of  three  types : 

1.  Bacteriuria  or  pyuria  without  symptoms. 

2.  Painful  symptoms,  with  pyuria. 

3.  Toxic  and  septic  symptoms,  with  pyuria. 

These  clinical  types  are  not  mutually  exclusive.  Indeed,  many 
patients  during  the  gTeater  part  of  the  course  of  their  disease  suffer 
no  subjective  symptoms  at  all,  and  may  be  classed  under  the  first 
type.  But  from  time  to  time  they  not  only  develop  painful  symptoms 
or  septic  or  toxic  symptoms,  but  also  may  suffer  intercurrent  attacks 
of  acute  infection.  The  more  acute  attacks  are  likely  to  occur  in  one 
kidney,  yet  not  only  is  it  almost  the  universal  rule  that  both  kidneys 
are  infected,  but  it  is  also  quite  usual  that  the  diminution  of  function 
is  almost  as  marked  in  the  silent  kidney  as  it  is  in  the  painful  or  tender 
kidney.    Such  cases  are  manifestly  poor  subjects  for  nephrectomy. 

Stone,  either  primary  (the  cause  of  infection)  or  secondary  (the 
result  of  infection),  is  a  very  common  complication  of  chronic  pyelo- 
nephritis. 

The  prognosis  of  these  chronic  renal  infections  is  bad.  The  milder 
types  are  indeed  curable,  and  even  if  not  cured  may  continue  for  many 
years  without  gravely  impairing  the  patient's  health.  So  long  as  the 
kidney  drainage  is  good,  the  patient  may  scarcely  call  himself  sick, 
although  he  may  have  had  an  active  chronic  pyelonephritis  for  many 
years.  Complicating  stone,  even  though  this  grow  to  an  enormous  size, 
and  thereby  hasten  the  destruction  of  kidney  parenchyma,  does  not 
portend  an  immediate  fatal  issue  unless  the  stone  obstructs  the  ureter, 
a  thing  which  it  is  likely  ultimately  to  do.  But  I  have  known  several 
cases  to  continue  in  very  good  health  for  thirty  or  forty  years,  even  with 
stone  (PI.  VI). 

The  ultimate  outcome  of  chronic  renal  infection  is,  however,  the 
total  destruction  of  the  kidney  parenchyma  by  chronic  inflammation. 
If  retention  predominates  over  infection,  the  result  is  infected  hydro- 
nephrosis. If,  as  is  more  commonly  the  case,  infection  predominates 
over  retention,  the  result  is  pyonephrosis. 

BACTERIURIA 

Bacteriuria  ^  is  a  clinical  rather  than  a  pathological  condition.    The 
bacteriuria  is  spoken  of  as  partial  when  the  bacteria  are  derived  from 
^  Ten  Broeck,  Surg.,  Gyn.  and  Ohst.,  1916,  xxii,  349. 


342  CLINICAL  PICTURE  OF  RENAL  INFECTION 

the  prostate  and  the  urine  from  the  kidneys  is  uninfected.  Bacteriuria 
is  total  when  caused  by  a  lesion  in  the  kidney  pelvis. 

The  bacteria  may  be  so  few  as  not  to  produce  any  pus,  not  to  cloud 
the  urine,  and  not  to  be  discernible  even  by  smear.  Only  culture  re- 
veals them.  Such  a  condition  may  exist  quite  unsuspected  for  many 
years.  Indeed,  the  majority  of  acute  renal  infections  in  young  children, 
though  they  apparently  terminate  and  leave  the  patient  in  perfect 
health  with  no  visible  pus,  bacteria  or  albumin  in  the  urine,  actually 
continue  in  this  occult  type  of  bacteriuria.  Let  such  a  patient  be  sub- 
jected to  one  of  the  accessory  causes  of  infection  and  acute  renal  in- 
fection promptly  occurs. 

Eoss/  for  example,  made  a  bacteriological  study  of  106  children's 
urines.  He  found  43  cases  of  bacillus  coli  infection.  Among  these  only 
3  had  a  frank  pyuria,  12  had  a  pure  bacteriuria  without  pus,  and  6 
revealed  bacilli  only  to  culture.  Among  19  supposedly  normal  cases, 
8  were  contaminated  with  staphylococcus  albus. 

The  condition  commonly  spoken  of  as  bacteriuria,  however,  is  that 
in  which  the  urine  is  swarming  and  clouded  with  bacteria,  but  contains 
no  more  than  a  few  pus  cells.  Like  the  condition  just  described,  it 
is  actually  a  form  of  mild  pyelonephritis,  and  if  the  case  is  closely 
watched  for  a  considerable  time,  and  repeated  urinalyses  made,  pus 
will  be  found  in  the  urine  from  time  to  time.  Indeed,  a  transitory 
bacteriuria  may  be  noted  at  the  onset  and  close  of  many  acute  attacks 
of  renal  infection. 

The  bacteria  of  bacteriuria  are  those  of  renal  infection.  Thus 
Suter  ^  collected  169  cases  showing  bacillus  coli,  13  showing  staphylo- 
cocci, 9  showing  streptococci,  and  6  showing  other  bacteria. 

Bacteriuria  is  usually  symptomless.  But  it  may  cause  any  of  the 
symptoms  of  pyelonephritis. 

PYURIA 

Pyuria  without  symptoms  is  but  evidence  of  an  infection  somewhat 
more  grave,  and  definitely  more  progressive  than  that  which  causes 
simple  bacteriuria. 

Urinalysis  of  the  urine  obtained  from  a  case  of  total  or  renal  bac- 
teriuria usually  shows  a  trace  of  albumin  and  sometimes  a  few  casts 
and  epithelial  cells  from  the  kidney  pelvis.  But  all  of  these  may  be 
absent.  When  the  inflammation  is  severe  enough  to  cause  pyuria, 
however,  there  is  always  a  trace  of  albumin  in  the  urine,  usually  some 
cells  from  the  kidney  pelvis,  rarely  casts. 

The  absence  of  casts,  so  characteristic  of  all  forms  of  surgical  infec- 
tions of  the  kidney,  and  so  strikingly  different  from  the  conditions  in 

'^Lancet,  1915,  clxxxviii,   654. 

'^  Trans.  III.  Internat.  Urological  Assn.,  1914. 


CHRONIC  PYELONEPHRITIS  343 

medical  nephritis,  merits  attention.  A  long  and  careful  search  of  sev- 
eral specimens  of  urine  will  indeed  usually  be  rewarded  by  the  finding 
of  a  few  casts,  even  in  surgical  cases.  But  these  casts  when  found  are 
more  likely  to  be  hyaline  or  granular  than  pus  casts.  Therefore  it  seems 
probable  that  they  are  due  rather  to  an  associated  toxic  nephritis  than 
to  the  actual  bacterial  processes  in  the  kidney  parenchyma.  Be  this 
as  it  may,  the  characteristic  urine  of  renal  infection  does  not  contain 
casts. 

PAINTUL    SYMPTOMS 

The  characteristic  pain  of  acute  renal  infection  or  of  pyonephrosis 
is  felt  in  the  loin,  associated  with  tenderness  of  the  enlarged  kidney, 
and  obviously  due  to  tension  upon  the  renal  capsule. 

Such  pain  in  the  loin  may  exist  with  chronic  pyelonephritis;  but 
this  is  unusual.  The  pain  may  be  felt  rather  in  front  than  behind  and 
may  be  referred  to  the  gall-bladder  or  appendix  region,  or  to  corre- 
sponding points  on  the  left  side. 

The  characteristic  pain  of  chronic  infection  of  the  kidney  is  fre- 
quent and  painful  urination.  This  frequent  urination  is  apparently 
due  to  the  inflammation  of  the  kidney  pelvis  and  ureter.  The  cysto- 
scope  shows  that  it  is  not  associated  with  inflammation  of  the  bladder, 
yet  the  symptom  of  frequent  and  painful  urination,  whether  due  to 
simple  pyelonephritis,  stone  in  the  ureter,  tuberculosis  of  the  pelvis  of 
the  kidney,  or  to  cystitis,  has  no  distinguishing  characteristic.  The 
cause  of  the  frequent  and  painful  urination  can  be  diagnosed  only  by 
the  cystoscope.  This  frequency  is  more  commonly  associated  with  cal- 
culous or  tuberculous  pyelonephritis  than  it  is  with  the  type  of  which 
we  are  now  speaking. 

TOXIC    SYMPTOMS 

Toxic  symptoms  in  the  adult  are  rather  a  measure  of  renal  reten- 
tion than  of  renal  infection,  but  children  with  chronic  renal  infection 
often  exhibit  one  or  the  other  of  the  types  of  toxic  symptoms  although 
they  apparently  have  no  gross  retention  of  virine  in  the  kidney  pelvis 
or  bladder.    The  toxemia  of  renal  infection  shows  itself  in  five  types : 

Digestive  symptoms. 

Cerebral  symptoms. 

Hiccough. 

Rheumatism. 

(High  blood  pressure.) 

Digestive  Symptoms — The  digestive  symptoms  of  renal  insuffi- 
ciency if  mild'may  be  due  either  to  infection  or  to  retention.  If  severe 
they  are  commonly  considered  evidence  of  renal  retention. 

Superficially  these  digestive  symptoms  resemble  those  of  so-called 


344  CLINICAL  PICTURE  OF  RENAL  INFECTION 

chronic  indigestion.  The  bowels  are  likely  to  be  constipated,  the  patient 
thin,  sallow  and  anemic,  the  appetite  fanciful,  and  the  patient  usually 
complains  of  various  abdominal  discomforts,  lassitude  and  loss  of 
weight.  But  the  striking  feature  of  this  toxemia  is  what  the  French 
call  "buccal  dysphagia" ;  subjective  if  the  toxemia  is  mild,  objective  if 
it  is  severe.  In  mild  cases  this  amounts  to  little  more  than  a  dryness 
and  stickiness  about  the  tongiie  and  the  pharynx  which  the  patient 
may  vainly  endeavor  to  control  by  drinking  large  quantities  of 
water. 

In  the  severe  cases,  the  tongue  not  only  feels  dry,  but  is  visibly  dry, 
parched,  red,  pointed,  and  may  even  be  cracked  and  fissured.  The 
condition  of  the  tongue  is  one  of  the  most  dependable  physical  signs 
in  the  prognosis  of  urinary  infection.  As  the  renal  function  is  more 
and  more  impaired,  the  tongue  and  pharynx  grow  dryer  and  dryer; 
while  if  improvement  occurs,  the  moistening  of  the  tongue  is  often 
one  of  the  first  signs  of  this  (PL  XII). 

When  the  tongue  is  moderately  dry  the  patient  actually  cannot 
eat  dry  solid  food.  If  the  tongue  is  excessively  dry,  he  cannot  even 
swallow  fluids. 

Cerebral  Symptoms — Cerebral  symptoms,  arising  from  renal  infec- 
tion, belong  rather  to  pyonephrosis  than  to  pyelonephritis.  Yet  the 
very  rarity  and  obscurity  of  such  symptoms  when  arising  without  an 
evident  septic  cause  is  enough  to  make  them  remarkable  in  this  con- 
nection. Cerebral  symptoms  indicate  grave  inhibition  of  the  renal 
function. 

The  cerebral  symptoms,  if  mild,  consist  of  little  more  than  an  undue 
irascibility  and  inability  to  sleep,  with  some  tendency  to  headache.  If 
more  severe,  the  patient  becomes  flighty  at  night,  but  is  likely  to  be  quite 
rational  during  the  day.  Rarely  there  may  be  attacks  of  excitement 
approaching  the  maniacal.  The  most  severe  symptoms  are  seen  only  in 
connection  with  the  digestive  symptoms,  and  the  characteristic  dry 
tongue.  The  patient  is  quite  incoherent,  and  usually  rather  inclined  to 
be  dull,  stuporous  and  comatose  than  excitable. 

Hiccough. — Persistent  hiccough,  like  the  dry  tongue  and  the  cere- 
bral symptoms,  is  an  ominous  sign  of  grave  impairment  of  the  renal 
function.  Such  being  the  case,  we  may  remark  parenthetically,  that  it 
is  quite  futile  to  attempt  to  treat  persistent  hiccough  by  any  remedy 
excepting  those  designed  to  eliminate  the  poisons  that  the  kidney  cannot 
transmit. 

Rheumatism — Although  toxic  pains  in  various  parts  of  the  body 
form  part  of  the  picture  of  any  grave  toxemia,  rheumatism  of  any  im- 
portance is  not  usTuilly  due  to  toxemia  of  renal  origin. 

High  Blood  Pressure — High  blood  pressure  is  a  characteristic  sign 
of  the  toxemia  of  non-bacterial  nephritis.    This  may  well  be  associated 


PLATE    XT! 


^-.-^s^r 


\ 


,     The  Tongue  of  Urinahy  Septicemia. 

The  tongue  is  parched,  scarlet,  narrow,  and  pointed.     It  is  oft-en  c()ver(>fl  with  a  tliicii 
coat,  and  may  be  cracked,  as  shown  in  plate. 


CHRONIC  PYELONEPHRITIS  345 

with  bacterial  nephritis,  but  the  toxemia  of  the  latter  does  not  cause 
elevation  of  the  blood  pressure. 

SEPTIC   SYMPTOMS 

The  septic  type  of  renal  infection,  urinary  septicemia  or  urosepsis 
(by  which  name  it  is  more  familiarly  called),  is  an  infection  character- 
ized by  an  irregular  temperature  which,  when  severe,  is  likely  to  be 
associated  with  chills  and  a  fever  curve  of  the  picket-fence  type,  usually 
accompanied  by  some  of  the  toxic  symptoms  above  described,  notably 
the  buccal  dysphagia,  and  which,  like  any  other  sepsis,  depends  for 
its  intensity,  its  gravity  and  its  continuance  upon  the  virulence  of 
the  infective  microorganism,  and  the  physical  condition  under  which 
it  is  acting. 

Urinary  septicemia  has  no  distinguishing  characteristics,  excepting 
its  tendency  to  produce  a  buccal  dysphagia  and  the  fact  that  it  is  asso- 
ciated with  impairment  of  the  renal  function,  and  pus  and  bacteria  and 
albumin  in  the  urine. 

Urethral  Chill — Urethral  chill  is  the  only  form  of  urinary  septi- 
cemia that  requires  special  mention.  Urethral  chill  is  a  very  acute 
infection  following  instrumentation  of  the  posterior  urethra.  In  its 
most  characteristic  form  it  consists  of  a  chill,  and  a  very  sharp  rise 
of  temperature  (even  to  106°  F.)  following  immediately  upon  the  first 
urination  after  the  passage  of  a  urethral  instrument.  Within  a  few 
hours  the  temperature  falls  to  normal.  This  may  be  followed  by  a  few 
slight  variations  of  temperature  before  the  attack  is  concluded  in  the 
course  of  24  to  48  hours.  But  it  may  be  only  the  first  of  a  number  of 
chills,  and  may  thus  prelude  a  chronic  septicemia. 

The  occasion  of  urethral  chill  is  so  manifestly  the  passage  of  an 
instrument  through  the  prostatic  urethra  that  it  used  to  be  considered 
of  purely  urethral  origin,  and  much  has  been  written  to  endeavor  to 
explain  the  combination  of  shock  and  sepsis  which  should  cause  so 
violent  a  reaction.  But  careful  observation  of  the  patient  both  before, 
durine:  and  after  urethral  chill  will  disclose  the  fact  that  three  elements 
are  necessary  and  one  usual  to  its  occurrence.  The  three  necessary 
elements  are:  chronic  prostatitis,  some  form  of  impairment  of  the 
renal  function,  usually  chronic  pyelonephritis  or  pyonephrosis,  and  the 
passage  of  a  urethral  instrument.  The  usual  element  which  combines 
all  three  of  these  cases  is  retention  due  to  stricture  or  prostatism,  requir- 
ing catheter  or  sound. 

Urethral  chill  is  actually  the  clinical  evidence  of  acute  infection 
in  a  chronically  inflamed  kidney  from  bacteria  delivered  into  the  circu- 
lation from  an  inflamed  prostate  by  means  of  the  trauma  of  urethral 
instrumentation.      The   reason  why  urethral   chill   so  often-  does  not 


346  CLINICAL  PICTURE  OF  RENAL  INFECTION 

inaugurate  a  chronic  sepsis  is  because  the  drainage  of  the  urinary  pas- 
sages in  the  cases  of  urethritis  and  stricture,  in  which  urethral  chill 
is  most  characteristically  seen,  is  usually  good,  and  gives  no  occasion 
for  prolongation  of  the  acute  renal  infection. 


SYMPTOMS  OF  PYONEPHROSIS 

In  its  clinical  picture  pyonephrosis  combines  the  symptoms  of 
chronic  pyelonephritis  with  urosepsis,  and  sometimes  with  the  more 
acute  symptoms  of  acute  renal  infection. 

The  striking  symptoms  are  usually  those  of  urinary  septicemia: 
mild  toxic  symptoms  if  the  infection  is  of  low  virulence ;  severe  septic 
symptoms  if  it  is  more  active. 

The  Urine. — The  urine  of  pyonephrosis  always  contains  pus.  For 
though  the  pyonephrosis  itself  may  be  closed,  the  opposite  kidney  is 
always  infected.  If,  as  is  usually  the  case,  the  pyonephrosis  is  open 
and  delivering  pus  into  the  bladder,  this  pus  will  usually  be  discharged 
intermittently.  The  pus  thus  delivered  is  thick,  ropy,  greenish  and 
settles  to  the  bottom  of  the  urine  in  a  flat  mud  quite  different  from 
the  pus  of  the  milder  renal  infections,  and  notably  different  from  the 
lighter  pus  of  cystitis.  The  renal  function  is  always  notably  impaired, 
and  even  the  mixed  urine  is  usually  watery  and  of  low  specific 
gravity  (PI.  XIII). 

Cystoscopy — This  reveals  a  dilated  distorted  ureter  mouth  sur- 
rounded by  inflammation  (though  exceptionally  this  inflammation  of 
the  ureter  may  have  subsided,  and  its  mouth  look  not  far  from  normal), 
or  a  golf  hole  or  retracted  tunnel-entrance  ureter  mouth.  If  the 
pyonephrosis  is  discharging  pus  at  the  time  of  the  cystoscopy,  this  pus 
is  likely  to  appear  as  a  thick,  white  ribbon  drooling  from  the  ureter. 
If  ureter  catheterization  is  possible,  in  spite  of  the  various  kinks  and 
scars  in  the  ureter,  the  urine  obtained  from  the  kidney  may  show  a 
surprisingly  large  percentage  of  urea  (as  high  as  1.5  per  cent).  But 
the  phenolsulphonephthalein  output  is  always  low. 

The  opposite  kidney  will  habitually  be  found  infected.  Usually 
its  function  will  be  found  gravely  impaired,  although  it  has  shown  no 
clinical  signs  of  active  inflammation. 

Palpation  of  the  Kidney. — Palpation  of  the  kidney  which  reveals 
little  or  nothing  in  most  cases  of  pj^elonephritis,  usually  reveals  a  very 
large  kidney,  and  sometimes  a  sensitive  one  if  there  is  pyonephrosis. 
The  increased  size  of  the  kidney  may  be  due  to  the  large  size  of  the 
pyonephrotic  sac,  but  often  it  is  due  to  the  great  mass  of  perirenal 
fibrolipoma. 

There  may  or  may  not  be  pain  in  the  loin. 


SYMPTOMS  OF  PERINEPHRITIS  347 

SYMPTOMS  OF  PERINEPHRITIS 

Fibrolipomatous  perinephritis  produces  no  symptoms. 

Suppurating  perinephritis  (perinephritic  abscess)  produces  a  clin- 
ical picture  similar  to  that  of  acute  renal  infection.  Indeed  since  the 
perinephritic  abscess  originates,  as  a  rule,  in  an  acute  cortical  abscess 
of  the  kidney,  it  is  quite  futile  to  attempt  to  distinguish  the  two  too 
precisely  in  their  earliest  stages.  But  when  this  acute  stage  has  passed, 
chronic  perinephritic  abscess  differs  markedly  in  its  characteristics  from 
chronic  pyelonephritis. 

Acute  Perinephritic  Abscess — Suppurative  perinephritis  is  usually 
the  result  of  staphylococcus  or  streptococcus  infection.  It  results  from 
injury  or  from  any  form  of  staphylococcus  or  streptococcus  septicemia. 
It  is  frequently  due  to  furunculosis. 

The  acute  attack  begins  precisely  as  an  acute  renal  infection,  but 
often  no  pus  appears  in  the  urine,  the  function  of  the  affected  kidney 
is  not  notably  impaired,  and  the  infecting  organism  may  or  may  not 
be  retrieved  by  culture  from  the  urine  of  the  infected  kidney.  Chills 
are  common,  renal  tenderness  and  later  muscular  rigidity  the  distin- 
guishing signs.  The  kidney  is  likely  to  be  large,  and  may  well  be  pain- 
ful as  well  as  tender.  Respiration  and  muscular  movements  are  likely 
to  increase  it  rather  more  than  is  the  case  with  a  similar  tenderness 
within  the  kidney. 

If  not  promptly  drained,  the  patient  may  die  of  sepsis,  the  abscess 
may  become  chronic  or  spontaneous  recovery  may  possibly  occur  by 
rupture  of  the  abscess  through  the  skin  or  into  one  of  the  neighboring 
viscera,  or  even  by  resorption  of  the  pus.  In  view  of  the  safety  of 
surgical  treatment,  however,  it  would  be  madness  to  delay  drainage  in 
the  hope  of  any  such  happy  issue. 

Chronic  Perinephritis — Chronic  perinephritis  doubtless  always  be- 
gins acutely;  but  the  acute  attack  may  be  so  mild  as  to  be  overlooked. 
Like  pyelonephritis  it  may  run  a  silent  afebrile  type  characterized  by 
an  increasing  mass  in  the  loin  which  is  often  not  very  tender,  and  the 
outlines  of  which  are  relatively  vague. 

More  commonly  the  course  of  the  suppuration  is  marked  by  a  picket- 
fence  temperature,  the  patient  is  gravely  septic ;  but  even  then  he  may 
make  no  complaint  of  his  loin,  and  the  urine  may  be  free  of  pus. 

In  adults  chronic  perinephritic  abscess  may  be  quite  definitely  dis- 
tinguished from  intrarenal  suppuration,  though  if  the  suppuration  is 
advanced  and  the  history  obscure,  it  may  be  quite  impossible  to  tell 
whether  the  pus  originated  within  the  kidney  or  from  some  other  retro- 
peritoneal source.  The  fully  developed  perinephritic  abscess  is  fixed 
rather  than  movable,  diffused  rather  than  clear-cut  in  its  outline,  asso- 


348  CLINICAL  PICTURE  OF  RENAL  INFECTION 

ciated  with  relatively  marked  rigidity  and  even  edema  of  the  overlying 
parietes. 


SYMPTOMS  OF  CERTAIN  CLINICAL  TYPES  OF  RENAL 

INFECTION 

Although  the  pathological  and  clinical  picture  already  described 
covers  the  various  types  of  renal  infection  whether  acute  or  chronic, 
whether  occurring  in  infancy  or  in  pregnancy,  whether  due  to  urethral 
or  ureteral  retention,  nevertheless  certain  clinical  types  of  renal  infec- 
tion exhibit  certain  dominant  characteristics  which  merit  notice.  We 
may  enumerate : 

Henal  infection  in  infancy. 

Eenal  infection  in  pregnancy. 

Eenal  infection  due  to  urethral  retention. 

Renal  infection  following  surgical  operation. 

Renal  infection  due  to  typhoid  fever. 

Renal  infection  due  to  the  gonococcus. 

Renal  Infection  in  Infancy. — Renal  infections  ^  are  extremely  com- 
mon in  infants  under  two  years  of  age.  They  are  said  to  be  ten  times 
more  frequent  in  girls  than  in  boys.  The  acute  onset  may  be  so  mild 
as  to  be  overlooked,  though  usually  it  is  very  stormy.  Thus  we  may 
describe  the  acute  and  the  chronic  type  of  infection. 

Acute  renal  infection  in  infancy  (usually  spoken  of  as  the  pyelitis 
of  infancy)  is  usually  a  stormy  attack  with  chills  and  high  fever,  ten- 
derness in  the  loin,  rigidity  of  the  overlying  muscles,  enlargement  of 
the  kidney.  These  local  signs  have  to  be  sought  for,  for  the  infant  does 
not  localize  its  pain.  The  debility  of  the  patient  is  relatively  slight 
as  compared  with  the  fever.  It  is  said  that  malaria  and  acute  renal 
infection  are  the  only  causes  of  septic  fever  with  repeated  chills  in 
infants. 

Though  the  attack  is  often  very  acute,  it  rarely  requires  surgical 
treatment.  The  patients  ultimately  recover,  or  pass  into  the  chronic 
type  of  renal  infection. 

Chronic  renal  infection  in  infants  is  a  toxemia  of  the  mild  digestive 
type.  There  may  be  no  fever ;  there  may,  from  time  to  time,  be  acute 
attacks  of  infection.  The  kidney  is  not  likely  to  be  tender.  The  diag- 
nosis depends  upon  the  examination  of  a  specimen  of  urine  obtained 
by  catheter.  Unfortunately  the  attending  physician  is  very  unlikely 
to  think  of  this  means  of  diagnosis. 

Townsend  has  called  attention  to  the  fact  that  chronic  perinephritis 

^Cf.  Friedenwaki,  Archiv.  of  Pediat.,  Nov.,  1910;  Bremmermau,  Jour.  A.  M.  A., 
Mar.  4,  1911;  and  Jeffreys,  Quart.  Jour.  Med.,  Apr.,  1911. 


SYMPTOMS  OF  CLINICAL  TYPES  OF  RENAL  INFECTION     349 

occurs  in  cliildren  causing  lameness  and  muscular  rigidity  as  its  most 
striking  symptom,  and  is  usually  mistaken  for  spondylitis  or  hip  dis- 
ease, or  even  for  psoas  abscess.  The  diagnosis  can  often  be  made  only 
by  operation. 

Renal  Infection  in  Pregnancy. — We  have  as  yet  no  adequate  data 
to  help  us  determine  what  proportion  of  renal  infections  occurring  dur- 
ing pregnancy  are  derived  from  latent  infections  of  childhood. 

The  infection  may  be  bilateral,  but  the  acute  infection  is  almost 
always  in  the  right  kidney.  The  chronic  infection  is  almost  always  mis- 
taken for  toxic  albuminuria  from  which  it  can  only  be  distinguished  by 
the  examination  of  a  specimen  obtained  by  catheter  from  the  bladder. 

Acute  renal  infection  occurs  on  the  right  side,  is  more  frequent  in 
primiparae  than  in  multiparae.  It  may  occur  as  early  as  the  third 
month,  but  is  most  common  from  the  seventh  to  the  tenth  month.  Not 
a  few  cases  come  to  operation  several  weeks  after  the  child  is  born. 

The  prognosis  of  the  attack  depends  almost  entirely  upon  the 
treatment.  Early  and  appropriate  treatment  should  save  the  child 
from  premature  delivery,  the  mother  from  operation. 

Renal  Infection  Due  to  Retention.^ — Renal  infection  is,  as  we  have 
previously  said,  usually  due  to  some  type  of  retention.  This  retention 
is,  in  many  instances,  slight  and  intermittent.  It  may  be  not  sufficient 
to  cause  any  retention  of  urine  in  the  renal  pelvis,  but  only  a  conges- 
tion of  the  pelvis  and  kidney  resulting  from  the  slight  tension  within 
them.  Under  such  circumstances  the  dilatation  of  the  kidney  pelvis 
from  retention  is  a  very  slow  process. 

But  in  the  type  of  renal  infection  of  which  we  are  now  speaking, 
the  dilatation,  due  to  gross  retention,  is  the  predominant  feature.  The 
retention  may  be  urethral  or  ureteral.  If  urethral,  the  retention  is  felt 
in  both  kidneys.  But  a  secondary  kinking  of  the  dilated  ureter  may 
cause  an  additional  retention  in  one  kidney  as  compared  to  the  other. 
Thus  in  urethral  cases  we  may  see  pyonephrosis  of  one  side,  and  pyelo- 
nephritis of  the  other. 

The  retention  may  come  on  gradually,  or  suddenly,  the  infection 
may  precede  the  retention,  and  be  lighted  up  by  this,  or  the  retention 
may  exist  for  some  time  before  infection  occurs. 

The  most  interesting  type  of  retention  infection  is  that  due  to 
catheterization  for  the  relief  of  prostatic  retention.  Such  retention, 
if  chronic,  may  be  considerable,  and  yet  may  have  accumulated  so 
gi'adually  that,  previous  to  the  interference  of  catheterization,  the  bal- 
ance of  forces  may  have  been  so  even  that  the  kidneys,  as  tested  by 
phenolsulphonephthalein,  may  be  working  quite  well.  But  the  passage 
of  the  catheter  upsets  the  balance,  excites  an  acute  congestion  of  the 
kidney,  and  prepares  the  way  for  the  infection  that  is  soon  to  follow. 

^  Cf .  Symposium  in  Cincinnati  Lancet-Clinic,  1916,  cxv,  118. 


350  CLINICAL  PICTURE  OF  RENAL  INFECTION 

The  meclianism  of  this  infection  has  been  ilhistrated  ou  page  290.  The 
kidneys  become  acutely  infected,  the  output  of  solids  falls,  the  tempera- 
ture rises,  pus  and  bacteria  appear  in  the  urine.  The  patient  goes  into 
a  condition  of  urinary  sepsis  more  or  less  gTave  in  proportion  to  the 
renal  destruction  that  had  preceded  infection  and  the  intelligence  of  the 
subsequent  treatment. 

Renal  Infection  Following^  Surgical  Operations. — Eenal  infection  is 
likely  to  complicate  the  convalescence  from  surgical  operation  under 
three  circumstances : 

1.  The  patient  has  an  unsuspected  cause  of  urinary  retention, 
usually  prostatism.  The  acute  retention  following  operation  calls  atten- 
tion to  this  condition  for  the  first  time,  and  starts  him  on  the  active 
symptoms  of  prostatism. 

2.  Without  any  such  preexisting  or  predisposing  cause  of  retention, 
the  patient's  calls  to  urinate  are  neglected  in  two  ways.  In  the  first 
place,  while  retention  is  still  complete  the  house  staff  neglect  to  pass 
the  catheter  as  often  as  is  required  to  keep  the  patient  comfortable. 
In  the  second  place,  when  the  patient  begins  to  urinate  he  does  not  fully 
empty  the  bladder,  but  he  is  then  considered  safe  from  any  complica- 
tions, and  no  further  attention  is  paid  to  the  bladder  retention  until 
infection  supervenes. 

3.  The  operation  itself  may  have  been  a  cause  of  retention  or  infec- 
tion. The  most  annoying  type  of  this  condition  is  that  type  following 
the  Wertheim  operation  with  stripping  of  the  pelvic  ureter  for  a  con- 
siderable distance.  This  results  in  ureteral  atony,  dilatation  and 
infection. 

It  will  be  noted  that  each  one  of  these  types  of  retention  is  due  to 
a  neglect  on  the  part  of  the  house  staff  to  appreciate  the  actual  con- 
dition present.  If  a  patient  has  to  be  catheterized  but  once  or  twice 
after  operation,  no  harm  is  likely  to  result.  But  if  continued  catheteri- 
zation is  necessary,  the  case  should  be  looked  upon  as  quite  comparable 
to  one  of  prostatism,  and  treated  accordingly. 

Renal  Infection  in  Typhoid — In  the  third  to  the  fifth  week  of 
typhoid  fever,  at  least  one  case  in  three  shows  typhoid  bacilli  in  the 
urine.  The  infection  is  usually  symptomless,  mild,  and  readily  con- 
trolled by  hexamethylenamin.  Indeed  as  a  rule  it  amounts  to  little 
more  than  a  bacteriuria  without  symptoms.  But  even  these  mild  cases 
may  continue  as  latent  infections  for  a  number  of  years,  and  then 
develop  evidences  of  more  severe  or  even  acute  infection.  Indeed, 
typhoid  infection  acts  as  a  mild  type  of  colon  infection  with  the  same 
possibility  of  acute  or  gTave  complications.  These  patients  are  more 
dangerous  to  others  as  typhoid  carriers  than  they  are  to  themselves. 

Renal  Infection  Due  to  Gonorrhea. — Pyelonephritis  is  not  an  un- 
usual accompaniment  of  a  severe  gonorrhea,  but  the  renal  infection  is 


SYMPTOMS  OF  CLINICAL  TYPES  OF  RENAL  INFECTION     351 

very  rarely  due  to  the  gonococcus.  The  cases  I  have  seen  have  all  but 
one  been  due  to  the  staphvlococcus  or  bacillus  coli,  usually  the  former. 
True  gonococcus  infection  of  the  kidney  is  usually  mild,  but  may 
be  tenacious.  It  seems  to  be  especially  amenable  to  treatment  by  pelvic 
lavage. 


CHAPTEE    XXXYI 
DIAGNOSIS  OF  RENAL  INFECTIONS 

The  diagnosis  of  renal  infection  presents  no  great  difficulties.  That 
it  is  so  often  overlooked  is  due  to  the  fact  that  the  idea  of  infection  never 
entered  the  physician's  mind. 

The  important  point,  therefore,  is  when  to  suspect  the  existence 
of  renal  infection.  Perhaps  the  injunction,  "alv^ays  to  be  sus- 
picious," would  best  cover  the  ground.  But  one  may  be  more  specific, 
as  follows : 

Suspect  renal  infection  when: 

A  child  has  chills  and  fever,  or  chronic  indigestion  with  slight  fever. 

When  a  pregnant  woman  has  fever  or  albuminuria  (either  during 
her  pregnancy,  or  during  the  puerperium). 

When  an  adult  has  an  obscure  sepsis,  especially  if  due  to  furuncu- 
losis  or  if  associated  with  a  dry  tongue,  pyuria  or  frequent  urination. 

When  a  patient  with  indigestion  complains  of  a  dry  tongue. 

When  a  patient  has  frequent  and  painful  urination,  and  pus  in  the 
urine,  remember  that  the  diagnosis  of  cystitis  is  meaningless  unless  its 
cause  is  known,  and  that  the  cause  of  "idiopathic"  inflammation  of  the 
bladder  is  usually  inflammation  of  the  renal  pelvis. 

Under  such  circumstances  the  diagnosis  of  renal  infection  is  made 
by  clinical  examination,  urinalysis  and  cystoscopy  and  the  ureter 
catheterization. 

PHYSICAL  EXAMINATION 

The  examination  consists  chiefly  in  the  ballottement  and  palpation 
of  the  two  kidneys  as  described  on  page  3.  The  experienced  observer 
will  readily  distinguish  by  palpation  between  enlargement  in  the  kidney 
itself,  and  the  less  movable,  less  well-defined,  more  edematous  and  boggy 
enlargement  due  to  perinephritic  abscess. 

But  palpation  cannot  usually  tell  us  the  precise  nature  of  an  en- 
largement of  the  kidney.  Xot  only  may  there  be  pyelonephritis  with- 
out enlargement,  but  it  may  often  be  impossible  to  palpate  the  difference 
between  hydronephrosis,  pyonephrosis,  compensatory  hypertrophy,  and 
neoplasm. 

Moreover  a  tender  kidney  is  not  necessarily  an  acutely  inflamed 

352 


OTHER  AGENCIES  FOR  DIAGNOSIS  353 

kidney.     A  kidney  which  is  the  seat  of  compensatory  hypertrophy  is 
often  not  only  painful,  but  also  quite  tender. 

URINALYSIS 

Urinalysis  has  been  almost  sufficiently  described  in  the  preceding 
chapter.  It  will  be  remembered  that  an  apparently  normal  urine  may 
be  obtained  by  ureter  catheter  from  an  inflamed  kidney  under  two 
conditions : 

1.  When  there  is  a  staphylococcus  or  streptococcus  focus  in  the 
parenchyma  threatening  to  break  into  the  perinephritic  tissue,  but  not 
communicating  with  the  pelvis,  the  urine  from  that  kidney  may  be 
entirely  normal,  and  its  function  unimpaired  (but  the  kidney  is 
tender).^ 

2.  Latent  bacillus  coli  infection  may  show  no  evidence  of  its  pres- 
ence except  the  fact  that  the  bacillus  may  be  cultured  from  the  appar- 
ently normal  urine. 

Albumin  may  be  equally  absent  in  cases  such  as  are  described  above, 
and  even  in  cases  of  slightly  greater  severity.  But  with  the  one  acute 
exception  noted,  any  infection  of  the  kidney  pelvis  worthj^  of  the  name 
includes  infection  of  the  parenchyma,  and  causes  albuminuria.  Albu- 
min, pus  and  bacteria  form  the  characteristic  combination.  The  ab- 
sence of  casts  is  rather  the  rule  than  the  exception  in  surgical  nephritis. 

Thus  simple  urinalysis  goes  rather  further  than  simple  palpation, 
and  usually  tells  us  that  there  is,  or  is  not,  renal  infection.  But  for  a 
more  precise  diagnosis  we  must  have  recourse  to  ureter  catheterization. 

THE  URETER  CATHETER 

With  the  exceptions  noted  in  the  preceding  paragraphs,  the  ureter 
catheter  may  be  depended  upon  to  give  a  precise  diagnosis  of  the  exist- 
ence of  renal  infection.  A  consideration  of  the  history,  presence  or 
absence  of  fever,  physical  conditions  within  the  kidney  as  revealed  by 
palpation,  urinalysis,  phenolsulphonephthalein  estimation,  and  ureter 
catheterization,  we  may  usually  arrive  at  a  precise  picture  of  the  patho- 
logical process,  and  of  its  bacterial  cause. 

OTHER  AGENCIES  FOR  DIAGNOSIS 

For  a  more  precise  diagnosis  as  to  the  presence  of  stone,  and  of 
dilatation,  and  the  position  of  ureteral  obstruction,  we  employ  the  x-ray, 
the  wax-tipped  catheter  and  pyelography. 

^  Under  tliese  circumstances  cocci  may  sometimes  be  demonstrated  in  the  urine 
"by  Crabtree's  fractional  centril'uge  metliod   (p.  13). 


354  DIAGNOSIS  OF  RENAL  INFECTIONS 

DIFFERENTIAL  DIAGNOSIS 

Diagnosis  of  the  renal  infection  is  readily  made  with  such  precision 
that  the  question  of  differential  diagnosis  only  arises  in  reference  to  the 
co-existence  of  other  conditions,  such  as  stone  (p.  392),  tumor,  tubercu- 
losis (p.  423),  or  infections  elsewhere  in  the  body.  It  must  not  be  for- 
gotten that  a  renal  infection  does  not  exclude  an  infection  elsewhere. 
A  tuberculous  kidney  is  apparently  proof  against  pyogenic  infection 
from  other  organisms,  but  the  opposite  kidney  to  a  tubercular  kidney 
may  be  thus  infected.  The  co-existence  of  tumor  and  infection  is  rare, 
excepting  in  the  case  of  old  calculous  infections  which  occasionally  lead 
to  carcinoma. 

PROGNOSIS 

The  prognosis  of  the  various  types  of  renal  infection  has  been 
described  with  sufficient  accuracy  in  giving  the  clinical  picture.  We 
may  once  again  insist  upon  the  need  of  immediate  operation  in  the 
treatment  of  fulminating  acute  infection,  and  of  perinephritic  abscess. 

One  must  also  remember  that,  not  only  may  a  pyelonephritis  remain 
entirely  latent  for  years,  but  also  a  more  severe  inflammation,  even 
though  it  show  a  definite  amount  of  albumin  and  pus  in  plenty,  has  a 
relatively  good  prognosis  in  that  it  may  continue  for  many  years  with- 
out destroying  life,  if  only  no  intercurrent  retention  or  other  complica- 
tions occur. 


CHAPTEK    XXXVII 
TREATMENT  OF  RENAL  INFECTIONS 

The  principles  of  tlie  treatment  of  renal  infection  are  deducible 
from  the  general  surgical  principles  involved.  The  infected  kidney  is 
a  suppurating  cavity,  usually  a  badly  drained  cavity.  Consequently 
the  first  and  foremost  indication  is  to  establish  good  drainage  whether 
for  prophylaxis  or  for  cure,  whether  by  posture,  by  ureteral  or  urethral 
catheter,  or  by  surgery. 

The  second  indication  is  antisepsis.  We  must  prevent  the  infection 
reaching  the  kidney  from  bowel,  bladder,  furuncle,  etc.  Once  the 
kidney  is  infected,  we  ply  the  patient  with  hexamethylenamin  and  per- 
haps add  pelvic  lavage  by  way  of  local  antisepsis.  We  modify  the 
acidity  of  the  urine  and  its  dilution  in  order  to  make  it  as  unfit  as 
possible  a  medium  for  the  growth  of  the  offending  organism. 

PROPHYLAXIS 

One  should  be  on  the  lookout  for  infection  of  the  kidney  whenever  a 
patient  suffers  from  constipation,  typhoid  fever,  retention  of  urine, 
furunculosis,  or  any  form  of  sepsis.  The  prevention  of  infection  from 
such  sources  generally  means  simply  the  elimination  as  rapidly  as 
possible  of  the  source  of  infection.  But  certain  types  of  prophylaxis 
require  special  insistence,  as  follows : 

Prevention  of  Urethral  Chill. — Urethral  chill  is  a  possible  compli- 
cation of  every  passage  of  an  instrument  into  the  urethra.  It  is  inevi- 
table if  retention  requires  a  retained  catheter  or  repeated  instrumenta- 
tion. The  prevention  of  infection  by  gentleness  during  manipulation, 
by  1  gram  of  hexamethylenamin,  three  times  a  day,  beforehand,  and 
an  instillation  of  1 :  500  silver  nitrate  following  the  instrumentation  as 
described  on  page  271  suffices  when  there  is  no  retention.  Chronic  re- 
tention, whether  due  to  prostatism,  bladder  paralysis,  diverticulitis,  etc., 
requires  the  same  gentleness  and  hexamethylenamin,  and  also  appro- 
priate bladder  drainage. 

Prevention  of  Infection  by  Posture — Since  the  so-called  spontane- 
ous infections,  notably  those  of  infants  and  young  women,  are  appar- 
ently due  to  renal  mobility,  these  may,  except  in  the  case  of  infants, 

3.55 


356  TEEATMENT  OF  REXAL  IXEECTIONS 

be  prevented  hy  training  in  proper  posture.  The  patient  should  spend 
at  least  an  hour  every  day  in  exercises  calculated  to  expand  the  lower 
chest,  by  throwing  the  shoulders  back,  the  chest  out,  the  hips  in,  the 
abdomen  in  and  the  toes  in.  In  addition  to  this,  the  patient  should  be 
encouraged  to  lie  flat  on  her  back  with  no  pillow  under  the  head,  and  a 
small  pillow  under  the  lower  chest,  below  the  shoulder  blades. 


TREATMENT  OF  ACUTE  RENAL  INFECTIONS 

Treatment  of  Mild  Cases. — Infection  of  a  well-drained  kidney,  even 

when  so  severe  as  a  urethral  chill,  may  recover  spontaneously  without 
treatment.  But  if  the  attack  of  fever  lasts  long  enough  to  bring  the 
patient  under  the  physician's  observation,  he  should  be  put  to  bed  at 
once,  kept  upon  his  back,  preferably  with  no  pillow  under  his  head, 
and  with  a  small  pillow  under  the  lower  ribs,  so  as  to  widen  the  lumbar 
recess.  After  a  single  purging  a  colon  irrigation  once  or  twice  a  day 
will  encourage  diuresis,  and  minimize  the  absorption  of  toxins  from 
the  bowel.  The  patient's  ears,  mouth,  abdomen  and  genitals,  both  in- 
ternal and  external,  should  be  carefully  investigated  for  possible  sources 
of  infection. 

The  medical  treatment  usually  employed  consists  in  the  adminis- 
tration of  large  quantities  of  water,  and  of  hexamethylenamin.  Hexa- 
methyJenamm  often  does  no  good  for,  like  other  solids,  it  is  not  excreted 
in  any  quantity  by  the  acutely  inflamed  kidney.  The  water  may  do 
positive  harm  by  putting  an  unnecessary  burden  of  work  upon  an 
already  impaired  organ.  It  is  usually  unnecessary  to  urge  more  water 
drinking  than  is  agTceable  to  the  patient. 

The  administration  of  large  doses  of  alkali  has  been  employed 
empirically  with  considerable  success  in  the  treatment  of  the  acute 
renal  infections  of  children.  Potassium  acetate  or  citrate  may  be  given 
in  doses  as  high  as  1  gram,  three  or  four  times  a  day,  even  to  children 
six  or  eight  years  of  age.  For  infants  the  alkali  may  be  mingled  with 
the  colon  irrigation  fluid,  1  gram  being  given  twice  a  day. 

The  alkaline  treatment  has  not  proven  particularly  successful  for 
adults.    But  it  is  more  efficient  than  the  traditional  hexamethylenamin.^ 

For  at  least  a  week  after  the  patient  is  out  of  bed  his  temperature 
should  be  closely  watched  as  moving  about  may  cause  a  relapse  of  the 
fever,  and  require  a  renewed  stay  in  bed. 

Treatment  of  Severe  Cases — The  management  of  the  more  severe 
cases  of  renal  infection  is  extremely  trying.  The  treatment  is  essen- 
tially the  same  as  that  described  above,  but  with  the  temperature  soaring 

*  The  alkalies  pass  through  the  glomeruli  and  elude  the  inhibition  of  function  of 
the  tubular  epithelia. 


DECAPSULATION  FOR  NONSURGICAL  NEPHRITIS  357 

occasionally  to  105°,  or  the  discouraging  relapses  after  a  few  days  of 
relatively  low  temperature,  one  is  tempted  to  unwise  experiments. 
Thus  vaccines  have  some  reputation  in  the  treatment  of  such  cases 
largely  because  the  patient  is  likely  to  get  well  at  about  the  time  the 
vaccine  is  employed.  Pelvic  lavage  also  has  some  reputation  though 
it  is  difficult  to  see  how  washing  out  the  cavity  of  the  pelvis  should 
benefit  an  acute  infection  of  the  parenchyma.  On  the  other  hand,  the 
single  passage  of  a  ureter  catheter  has  frequently  been  known  to  cut 
short  the  acute  attack.  Hence  this  should  be  employed  for  therapeutic 
as  well  as  for  diagnostic  purposes.  In  order  to  avoid  any  reaction  upon 
the  kidneys  through  the  passage  of  the  cystoscope,  it  is  prudent  to 
employ  the  small  single-catheterizing  instrument. 

Brewer  advises  decapsulation  for  doubtful  cases  which  do  not  seem 
to  require  nephrectomy.  I  have  never  attempted  the  operation  under 
these  circumstances,  and  doubt  its  value. 

Treatment  of  Fulminating-  Cases — Let  us  first  define  clearly  what 
we  mean  by  fulminating  cases.  There  are  three  types.  In  the  first, 
the  operative  indication  is  obvious.  The  patient  is  overwhelmed  by 
grave  septicemia;  the  temperature  runs  in  the  region  of  105°,  usually 
with  several  chills.  The  treatment  is  prompt  nephrectomy  after  ureter 
catheterization  has  established  the  sufficiency  of  the  opposite  kidney. 

But  there  are  fulminating  cases  in  which  the  patient's  condition  is, 
for  the  time  being,  apparently  very  good.  Yet  there  may  be  on  the  one 
hand  a  temperature  rising  to  105°,  and  staying  there  for  two  or  three 
days,  or  on  the  other  hand,  a  temperature  touching  that  point  repeatedly 
with  great  oscillation  and  repeated  chills.  Either  condition  is  an 
indication  for  operation.  Exploration  will  usually  reveal  a  large  purple 
organ  riddled  with  foci  of  suppuration.  Partial  nephrectomy  is  unsatis- 
factory patchwork. 

Treatment  of  Perinephritic  Cases. — Certain  cases,  especially  those 
causing  fever,  a  large  and  tender  kidney,  and  no  pus  in  the  urine,  require 
early  operation  for  the  drainage  of  the  abscess  in  the  parenchyma  and 
the  perinephritic  abscess  adjoining.  These  cases  escape  nephrectomy  if 
drained  early. 


DECAPSULATION  FOR  NONSURGICAL  NEPHRITIS 

The  Effect  of  Decapsulation  upon  the  Kidney — The  disappearance 
of  albuminuria  after  an  operation  j)erloruied  for  surgical  disease  of 
the  kidney  has  been  noted  by  various  authors,  and  is  not  a  very  un- 
common experience.  In  1901  Edebohls,^  having  observed  these  facts 
in  a  number  of  nephropexies,  conceived  the  idea  of  aiding  the  return 

^Med.  Eecord,  1901,  Ix,  690. 


358  TREATMENT  OF  RENAL  INFECTIONS 

to  normal  of  the  kidney  bj  stripping  from  it  its  fibrous  capsule,  on  the 
theory  that  tension  would  thus  be  relieved  and  that  the  new  capsule 
formed  from  the  cellular  tissue  about  the  kidney  might  prove  more 
vascular  than  the  old,  and  thus  supply  more  blood  to  the  kidney. 

Following  out  this  theory,  at  first  chiefly  upon  cases  of  albuminuria 
associated  with  nephroptosis,  later  upon  all  kinds  of  albuminurics, 
Edebohls^  reported,  in  1903,  51  cases,  of  which  14  per  cent  died,  M 
per  cent  improved,  and  14  per  cent  were  definitely  cured.  But,  in 
the  meanwhile,  Eovsing^  by  a  series  of  careful  investigations,  demon- 
strated that  bacterial  nephritis  (i.e.,  pyelonephritis),  or  nephritis  caus- 
ing renal  pain  or  hematuria,  could  be  cured  by  nephrotomy  with  decap- 
sulation, but  that  true  Bright' s  disease,  nonsurgical  nephritis,  could 
not  be  so  cured. 

Experiments  upon  dogs,  rabbits,  and  cats  have  shown  that  the 
capsule  of  scar  tissue  formed  after  decapsulation,  although  more  vas- 
cular at  first,  soon  develops  into  a  fibrous  layer  closely  resembling  the 
original  capsule,  and  is,  if  anything,  more  closely  adherent  to  the 
kidney.  Autopsy  reports  are  few  and  conflicting,  but  in  the  main 
confirm  this  view. 

Elliott  ^  collected  112  reported  decapsulations,  among  which  29 
cases  of  nephroptosis,  with  albuminuria,  operated  upon  by  nephropexy 
with  or  without  decapsulation.  Almost  all  did  well.  His  76  cases  of 
medical  nephritis  show  36  deaths,  14  unimproved,  26  improved  (?). 
Unfortunately  most  of  the  cases  were  last  reported  within  six  months 
after  operation.  Improvement  for  this  brief  space  is  doubtless  due  to 
the  relief  of  congestion.  Indeed  the  benefit  derived  from  decapsulation 
is  apparently  due  solely  to  this  relief  of  congestion,  not  to  any  perma- 
nent change  in  the  blood  supply. 

Edebohls  *  has  operated  upon  103  cases  and  observed  the  survivors 
for  at  least  fifteen  months.  Of  these,  11  died  as  a  result  of  operation, 
29  more  of  chronic  nephritis,  and  10  more  from  other  causes.  Of  the 
53  survivors,  Edebohls  estimates  11  as  improved,  33  as  cured.  Ede- 
bohls' definition  of  a  cure  is  the  absence  of  symptoms  of  nephritis  and 
entirely  normal  urine  for  six  months.  That  only  18  of  these  patients 
were  ''cured"  within  a  year  of  the  time  of  operation  probably  shows, 
contrary  to  Edebohls'  opinion,  how  independent  of  operation  these 
so-called  cures  are. 

It  is  the  consensus  of  opinion  that  decapsulation  may  be  beneficial 
to  the  acutely  congested  kidney,  whether  the  congestion  be  bacterial 
or  toxic,  but  that  it  is  of  no  service  in  chronic  nephritis. 

^Med.  Becord,  1903,  Ixiii,  481. 

"^  Mitteil.  mis  d.  GrensgeMet.  d.  Med.  u.  Chir.,  1902,  x,  288. 

^N.  ¥.  Med.  Jour.,  1904,  Ixxix,  1078. 

*Jour.  A.  M.  A.,  1909,  lii,  195. 


PLATE    XIII 


The  Urine  of  Pyonephrosis. 


The  urine  is  acid  and  milky  when  passed.  On  standing  it  becomes  almost  clear,  retaining 
only  a  bacterial  haze,  while  the  pus  accumulates  in  a  fiat,  cohesive,  yellow  or  greenish  mass 
at  the  bottom.  The  specific  gravity  of  this  urine  is  low,  and  the  amount  of  pus  varies  from 
day  to  day. 


PYELONEPHRITIS  WITHOUT  RETENTION  OR  SEPSIS        359 

TREATMENT  OF  PYELONEPHRITIS  WITHOUT  RETENTION  OR 

SEPSIS 

The  treatments  usually  employed  are :  hygiene,  hexamethylenamin, 
pelvic  lavage  and  vaccines. 

Hygiene — The  hygiene  is  that  of  chronic  nonbacterial  nephritis. 
If  the  kidney  function  is  definitely  impaired,  the  patient's  weight 
should  be  reduced  by  a  diet  free  from  alcohol  and  with  low  pro- 
portion of  nitrogen.  His  health  may  be  expected  to  improve  if  he 
keeps  in  the  open  air,  avoids  worry  and  hard  physical  and  mental 
exertion. 

Hexamethylenamin — ^Hexamethylenamin  is  all  but  synonymous 
with  urinary  antisepsis.  The  other  drugs  employed  for  this  purpose 
have  never  been  proven  to  have  any  value. 

Hexamethylenamin  is  a  combination  of  ammonia  and  formaldehyd. 
Its  only  effect  is  an  antiseptic  one,  due  to  the  liberation  of  formaldehyd 
from  it  in  acid  solution.  Hence  it  is  only  efficient  in  the  stomach  and 
in  the  urine.  The  liberation  of  formaldehyd  in  the  stomach  is  merely 
an  inconvenience  on  account  of  its  irritating  properties.  This  incon- 
venience may  be  overcome  by  administering  the  drug  in  salol-  or  keratin- 
coated  capsules.  The  observations  of  Burnam,^  George  Smith,^  Hin- 
man,^  and  others  have  shovsni  that  in  order  to  have  any  antiseptic  effect, 
the  formalin  liberated  in  the  urine  must  be  in  a  concentration  of  at 
least  1 :  30,000.  The  drug  must  be  administered  in  doses  of  at  least 
1  gram,  three  times  a  day,  to  obtain  this  concentration.*  Inasmuch  as 
the  drug  breaks  up  rather  slowly,  it  is  questionable  whether  it  is  often 
antiseptic  in  the  kidney  pelvis  at  this  dose  (Hinman).  It  is  likely  to 
have  no  value  in  acute  nephritis,  for  the  excretion  of  solids  is  notably 
reduced  under  these  circumstances,  so  that  the  excretion  of  hexamethyl- 
enamin must  be  very  small. 

The  theoretically  ideal  dose  is  2  grams,  four  times  a  day.  The 
effect  of  this  may  be  distinctly  increased  by  the  administration  of  acid 
phosphate  of  sodium,  2  to  3  grams  a  day  in  order  to  increase  the  acidity 
of  the  urine.  The  maximum  excretion  of  the  drug  occurs  within  a 
few  hours  of  its  administration. 

It  may  seem  wise  to  control  the  administration  of  hexamethylen- 

"■ArcUv.  of  Int.  Med.,  1912,  x,  324. 

^Boston  Med.  ^  Surg.  Jour.,  May  15,  1913,  clxviii,  713. 

^Jour.  A.  M.  A.,  Nov.  20,  1915,  Ixv,  1769. 

*  There  are  very  rare  exceptions  to  this  rule.  Persons  who  are  irritated  by 
small  doses  of  hexamethylenamin  sometimes  obtain  unquestioned  antiseptic  effect 
from  still  smaller  doses.  I  have  known  a  patient  who  could  not  keep  his  urine 
clean  in  any  other  way  to  keep  it  free  from  pus  for  years  by  doses  of  hexamethyl- 
enamin of  less  than  a  gram  a  day. 


360  TREATMENT  OF  RENAL  INFECTIONS 

amin  hj  Burnam's  test  for  formalin  in  the  urine.  Thereby  we  may 
estimate  the  proper  amount  in  order  to  get  a  given  result.  But  prac- 
tically speaking,  the  susceptibility  of  different  individuals  to  the  toxic 
action  of  the  drug  varies  greatly.  The  liberation  of  too  much  formalin 
in  the  urine  produces  frequent  and  painful  urination,  and  even  hema- 
turia. Warren  Coleman  ^  has  collected  a  number  of  cases  of  hematuria 
following  the  administration  of  very  small  doses.  A  single  dose  of  less 
than  a  gram  has  several  times  caused  this  result.  But  so  rare  is  this 
phenomenon  that  it  is  Usually  safe  to  begin  with  a  dose  of  1  gram, 
three  times  a  day,  and  increase  until  the  limit  of  toleration  is  found. 
If  the  urine  is  not  acid,  the  administration  of  the  drug  is  accompanied 
by  1  gram,  three  times  a  day,  of  acid  sodium  phosphate.  When  the 
limit  of  toleration  is  found,  the  drug  is  administered  at  a  point  just 
below  this.  If  no  benefit  is  obtained  in  the  course  of  a  week  or  ten 
days,  the  drug  may  as  well  be  abandoned. 

Pelvic  Lavage. — The  pelves  of  the  kidney  may  be  washed  out 
through  a  ureter  catheter,  once  or  twice  a  week.  The  most  valuable 
solution  for  this  purpose  is  silver  nitrate  in  strength  of  from  0.5  to 
1  per  cent.  ISTot  more  than  2  c.c.  should  be  injected,  and  this  should 
be  permitted  to  run  out  through  the  ureter  catheter.  Geraghty  ^  has 
advised  that  silver  be  used  in  as  high  as  5  per  cent  strength.  This  is 
very  painful,  but  he  states  that  it  cures  certain  cases  that  are  not 
cured  by  the  milder  solutions. 

Pelvic  lavage  should  not  be  employed  in  acute  cases,  in  cases  with 
retention  of  urine  in  the  kidney  pelves,  in  cases  with  definite  impair- 
ment of  the  function  of  the  kidney  as  estimated  by  the  phenolsulphone- 
phthalein  output.  Under  favorable  circumstances,  it  is  even  claimed 
(e.g.,  by  Geraghty)  that  favorable  cases  may  be  actually  cured  even 
of  a  bacillus  coli  infection  by  this  lavage.  Their  active  symptoms  may 
certainly  be  relieved. 

Vaccines — Vaccines,  whether  autogenous  or  stock,  are  of  no  value 
in  this  class  of  cases. 

Summary. — As  an  actual  fact  the  great  majority  of  the  mild  cases 
of  renal  infection,  without  sepsis  or  grave  retention,  do  not  even  come 
for  treatment.  They  consider  themselves  practically  well.  And  the 
most  mildly  infected  suffer  so  little,  and  are  offered  so  little  prospect 
of  help  by  any  treatment  that  one  cannot  blame  them  for  shirking. 
I  have  relieved,  but  never  cured,  such  cases  by  the  method  of  pelvic 
lavage.  I  have  also  known  them  to  be  relieved  by  high  doses  of  hexa- 
methylenamin.  I  have  seen  two  cures  result  from  treatment  at  a 
diuretic  spring  where  the  patient  for  several  weeks  drank  very  large 
quantities  of  water. 

^Medical  News,  August  29,  1903. 

'Jour.  A.  M.  A.,  December  19,  1914,  Ixiii,  2211. 


PYELONEPHRITIS  WITH  RETENTION  OR  SEPSIS  361 

TREATMENT  OF  PYELONEPHRITIS  DUE  TO  RETENTION   OR 

CAUSING  SEPSIS 

Whenever  renal  retention  is  diagnosed  the  relief  of  this  constitutes 
the  first  step  in  the  treatment  of  any  renal  infection,  acnte  or  chronic, 
mild  or  severe.  The  general  topic  of  renal  retention  is  discussed  under 
the  head  of  "Hydronephrosis."  But  renal  retention  is  often  silent  until 
infection  produces  symptoms. 

The  following  observations  may  prove  suggestive  in  the  treatment 
of  such  cases. 

In  Children — In  children  the  relief  of  renal  retention  is  accom- 
plished by  postural  exercises  as  already  described.  So  long  as  there  is 
no  stone,  gross  dilatation  of  the  kidney  is  not  likely  to  be  found  except- 
ing in  rapidly  fatal^ congenital  cases. 

In  Pregnancy.— ^Decubitus  with  a  pillow  under  the  lower  chest  may 
relieve  pressure  in  preg-nancy.  If  this  fails,  drainage  should  be  obtained 
by  the  indwelling  ureter  catheter.  It  is  scarcely  ever  necessary,  either 
to  perform  nephrectomy  for  a  fulminating  condition  (I  have  performed 
one  such),  or  to  terminate  the  pregTiancy.  Patient  and  intelligent  care, 
and  above  all  an  early  recognition  of  the  fact  that  the  patient's  albu- 
minuria is  due  to  retention  and  infection,  and  not  to  Bright's  disease, 
should  carry  her  through  her  pregnancy  safely. 

Urethral  Retention — This  is  a  common  cause  of  renal  infection. 
The  treatment  of  the  various  types  of  urethral  retention  need  not  be 
specified  here.  One  must  not  forget,  however,  that  a  virgin  may  have 
retention  of  urine  due  to  cystocele,  that  this  condition  is  very  common 
in  old  women,  and  that  stricture  of  the  urethra  is  very  commonly 
overlooked  'in  women.  The  fact  that  a  glass  catheter  will  enter  the 
bladder  by  no  means  shows  that  the  woman  has  not  a  stricture.  Her 
urethra  should  normally  take  a  24  to  26  sound. 

It  is  most  essential  to  remember  that  a  primary  cause  of  retention 
in  the  urethra  or  lower  ureter  may  so  dilate  the  canal  above  as  to  cause 
secondary  kinking  and  pouching  of  the  upper  ureter  and  kidney  pelvis. 
Under  such  circumstances,  the  relief  of  the  lower  retention  does  not 
accomplish  a  cure.  One  sees  this  commonly  in  cases  of  pyonephrosis 
due  to  urethral  stricture  or  prostatism,  the  pyonephrosis  being  kept  np 
by  a  ureteral  kink  after  the  urethral  retention  has  been  relieved. 
Stricture  at  the  ureter  orifice  or  stone  impacted  for  a  long  time  in  the 
lower  ureter  has  a  similar  effect  in  some  instances. 

ISTephropexy  may  cure  infection  due  to  slight  retention.  Pyelog- 
raphy and  careful  examination  of  the  kidney  pelvis  and  ureter  for 
kinks,  adhesions  and  dilatations  in  the  course  of  the  operation  will 
reveal  the  precise  condition  in  many  such  cases. 


362  TREATMENT  OF  RENAL  INFECTIONS 

TREATMENT  OF  URINARY  SEPTICEMIA 

The  treatment  of  acute  renal  infection,  including  urethral  chill, 
has  already  been  described. 

Urinary  septicemia  usually  depends  upon  some  form  of  retention  of 
urine  (whether  urethral  or  ureteral).  The  first  requisite  for  a  cure  is 
the  relief  of  this  retention. 

The  treatment  of  pyonephrosis  is  so  special  that  it  is  described 
separately. 

Vaccines — Vaccines  are  of  no  value  excepting  for  the  relief  of  toxic 
symptoms.  I  have  known  patients  to  derive  great  temporary  comfort 
from  the  use  of  vaccines,  but  have  never  seen  any  permanent  good 
results,  and  have  never  known  the  bacteria  or  the  pus  to  be  driven  from 
the  urine  by  their  use.  Generally  speaking,  they  are  not  worth  while, 
if  not  worse  than  useless  in  that  they  encourage  neglect  in  searching 
out  the  real  treatment ;  i.e.,  the  relief  of  the  retention. 

Pelvic  Lavage. — Lavage  of  the  kidney  pelvis  is  as  little  calculated 
to  do  good  when  there  is  chronic  retention  or  chronic  sepsis.  The  bene- 
fits attributed  to  the  lavage  are  doubtless  usually  due  to  the  passage  of 
the  ureter  catheter.  For  it  is  in  these  cases  especially  that  the  ureter 
catheter  is  singularly  valuable.  The  indwelling  ureter  catheter  will 
often  not  only  carry  one  by  a  difficult  stage  of  relatively  acute  infection, 
but  will  also  so  improve  the  ureteral  drainage  that  the  subsequent 
course  of  the  case  is  singularly  modified  for  the  good. 

Diuresis — After  the  retention  has  been  overcome,  catharsis  and 
diuresis  are  the  best  means  in  our  possession  for  the  combating  of  infec- 
tion and  sepsis.  In  really  acute  cases  diuresis  may  do  more  harm  than 
good  if  it  is  pushed  to  the  point  of  adding  to  the  congestion  of  the 
kidney.  Indeed  it  may  be  overdone  even  in  chronic  cases.  But  while 
there  is  actual  sepsis  the  patient  may  often  with  advantage  drink  8  to 
12  glasses  of  water  a  day,  and  receive  one  or  two  colon  irrigations.  The 
Murphy  drip  is  also  useful,  and  for  emergencies  intravenous  or  sub- 
cutaneous infusions. 

But  it  is  to  be  remembered  that  the  object  of  diuresis  is  simply  to 
free  the  kidney  of  solids;  to  keep  the  urine  at  relatively  low  specific 
gravity ;  to  do  exactly  what  catharsis  does  in  the  intestines.  The 
practice  of  depending  upon  water  alone  for  the  purpose  of  washing 
bacteria  out  of  the  kidney  is  scarcely  justified.  It  often  keeps  the 
patient  sick,  or  makes  him  sicker  by  adding  to  the  work  thrown  upon 
the  kidney. 


TREATMENT  OF  PERINEPHRITIS  363 

TREATMENT  OF  PYONEPHROSIS 

Pyonephrosis  is  a  surgical  condition,  its  treatment  is  operative.  It 
usually  requires  nephrectomy,  but  some  cases  recover  after  nephrotomv, 
and  many  die  after  nephrectomy  because  of  their  sepsis  and  of  the 
deficient  function  of  the  opposite  kidney.  Therefore,  one  may  specify 
as  follows  : 

Unless  the  function  of  the  opposite  kidney  is  found  to  be  perfectly 
adequate,  nontubercular  pyonephrosis  should  always  be  drained  for  a 
time  before  nephrectomy  is  undertaken.  Inasmuch  as  the  kidney  is 
usually  large,  the  drainage  may  be  established  without  disturbing  the 
kidney  in  its  bed. 

If  the  pyonephrosis  is  acute,  and  the  pus  in  the  kidney  has  accumu- 
lated rather  as  a  result  of  an  active  suppuration  than  as  a  result  of  a 
stoppage  in  the  ureter,  this  simple  drainage  may  cure  this  condition  by 
evacuating  the  thick  pus. 

If,  as  is  usually  the  case,  drainage  does  not  cure,  it  should  be 
continued  until  the  patient's  general  condition  and  the  function  of  the 
opposite  kidney  have  improved  as  much  as  may  be  expected;  then 
nephrectomy  is  performed. 

Plastic  operations  about  the  upper  end  of  the  ureter  are  not  to  be 
considered  as  a  means  of  curing  pyonephrosis. 

TREATMENT  OF  PERINEPHRITIS 

Fibrolipomatous  perinephritis  requires  no  treatment. 

Perinephritic  abscess  should  be  diagnosed  and  drained  as  early  as 
possible.  If  the  case  is  really  seen  early  the  focus  in  the  kidney  can 
usually  be  identified  and  curetted  so  that  it  may  drain  freely.  Whether 
it  is  wise  to  carry  the  incision  into  the  pelvis  of  the  kidney  for  the 
purpose  of  drainage  will  have  been  decided  by  the  observations  made 
by  ureter  catheter  before  the  operation. 

In  early  cases  the  situation  of  the  suppuration  within  or  without 
the  fascial  capsule  of  the  kidney  will  show  whether  its  origin  is  renal 
or  not.  But  if  the  abscess  is  of  long  standing,  the  primary  effort  should 
be  simply  to  drain  it,  leaving  the  treatment  of  other  lesions  for  subse- 
quent consideration. 

The  necessity  for  nephrectomy  is  determined  by  the  condition  of  the 
kidney.  It  is  usually  wise  to  postpone  nephrectomy  until  drainage  shall 
have  relieved  the  patient  of  his  sepsis. 


CHAPTER    XXXVIII 

CYSTITIS 

The  inflammations  of  the  bladder  are  reducible  to  a  very  small  num- 
ber of  clinical  types,  though  each  of  these  types  has  many  variations. 
Authorities  differ  so  widel}^  in  their  classifications  of  cystites  that  an 
accepted  classification  can  hardly  be  said  to  exist.  The  following 
simple  scheme  will  suffice  for  our  purposes : 


Nonbacterial  Cystitis ■<  ^,       .    , 

•^  (  Chemical 

Bacterial  Cystitis :  Simple 


Tubercular  Cystitis 


Traumatic. 

Chemi 

■  Acute. 

^,        .     I  Alkaline. 
Chrome  J       . , 
\  Acid. 

Interstitial. 

Pericystitis. 


The  nonbacterial  cases  will  be  dismissed  briefly.     Tubercular  cys- 
titis is  considered  in  a  subsequent  chapter. 


NONBACTERIAL  CYSTITIS 

TTonbacterial  cystitis  is  the  reaction  of  the  vesical  mucous  membrane 
to  a  mechanical  or  a  chemical  irritant. 

Traumatic  Cystitis — A  severe  inflammation  without  infection  may 
be  caused  by  stone  in  the  bladder  and  by  rough  instrumentation.  In 
such  cases  there  may  be  much  tenesmus  and  distress  together  with  blood 
and  pus  in  the  urine,  and  yet  no  true  infection. 

Treatment. — The  irritation  may  be  dispelled  by  removing  the 
cause.     It  may  be  mitigated  by  balsamics  and  anodynes. 

Chemical  Cystitis — Any  strong  irritant  entering  the  healthy  blad- 
der, whether  from  above  or  below,  causes  cystitis.  The  intense 
strangury  caused  by  the  administration  of  cantharides  has  acquired  an 
undeserved  notoriety  on  account  of  the  alleged  sexual  excitement  accom- 
panying it.  The  acute  prostatic  congestion  induced  by  this  drug  is  said 
to  cause  priapism,  but  the  sensations  of  the  patient  in  this  condition  are 
>    .   \  .364 


BACTERIAL  CYSTITIS  365 

anything  but  pleasant.  Rehn,  and  later  Lichtenstein/  have  called 
attention  to  a  similar  strangury  occurring  in  coal-tar  workers,  appar- 
ently due  to  inhalation  of  irritating  vapors.  Sarcoma  of  the  bladder 
occurs  in  some  of  these  cases.  The  irritation  due  to  hexamethylenamin 
ia  more  important,  since  that  drug  is  so  freely  used  nowadays. 

While  hyperacid  urine  is  somewhat  irritating  to  the  bladder,  am- 
moniacal  urine  is  far  more  so,  and  the  reason  why  an  ammoniacal  cys- 
titis is  likely  to  be  so  much  more  intense  than  an  acid  cystitis  is  doubt- 
less for  this  very  reason — that  the  ammonia  adds  fuel  to  the  fire  of 
bacterial  attack. 

Cystitis  may  equally  be  caused  by  irritants  introduced  through  the 
urethra.  Nitrate  of  silver  is  so  often  used  in  concentrated  solution  that 
it  bears  an  unenviable  notoriety  in  this  regard.  Such  chemical  cystitis 
may  be  followed  by  true  infection  of  the  bladder  and  also  of  the  kidney. 
Mock  ^  has  reported  two  cases  of  gangrene  of  the  bladder  following  injec- 
tions made  in  the  hope  of  producing  abortion. 

Treatment. — Removal  of  the  cause  constitutes  the  essence  of  treat- 
ment. To  allay  the  irritation  the  sedative  remedies  employed  in  bac- 
terial cystitis  may  be  used. 


BACTERIAL  CYSTITIS 

Cystitis  may  be  acute  or  chronic,  superficial,  interstitial,  or  com- 
plicated by  pericystitis. 

ETIOLOGY 

The  etiology  of  cystitis  has  been  considered  in  Chapter  XXXIII. 
The  conclusions  therein  reached  may  be  summed  up  as  follows : 

1.  Bacteria  may  reach  the  bladder  (1)  from  the  urethra,  (2)  from 
the  kidney,  and  less  often  (3)  by  irruption  of  a  neighboring  focus  of 
inflammation,  and  (4)  from  the  blood  or  the  lymph  vessels. 

2.  Bacteria  reaching  the  bladder  will  not  cause  any  inflammation 
of  that  organ  unless  there  is  congestion  due  to  (1)  retention,  (2)  trauma 
by  instruments,  stone,  or  foreign  body,  (3)  disease  of  the  bladder  wall, 
such  as  neoplasm,  tubercle,  or  simple  ulcer,  or  (4)  unless  the  disease 
extends  directly  to  the  bladder  from  the  neighboring  tissues,  the  ureter 
(tuberculosis)  or  the  urethra  (gonorrhea),  or  (5)  unless  the  bladder  is 
paralyzed. 

3.  A  cystitis  thus  begun  will  disappear  spontaneously  unless  it  is 
perpetuated  by  some  of  the  accessory  causes  enumerated. 

4.  Acid  cystitis  is  usually  caused  by  the  bacillus  coli,  the  tubercle 

^Deutsche  med.  Wochenschr.,  1898,  xxiv,  709. 
'Guyon's  Annales,  1911,  xxix,  1633. 


366  CYSTITIS 

bacillus,  the  typhoid  bacillus,  or  the  gonococcus.  Alkaline  cystitis  is 
due  to  staphylococcus,  streptococcus,  or  proteus  infection.  Exception- 
ally these  bacteria  cause  only  an  acid  cystitis. 

5.  Mixed  infection  is  much  more  frequent  in  the  bladder  than  in  the 
kidney.  The  pyogenic  cocci  predominate,  and  the  flora  of  cystitis  is 
much  more  variegated  than  that  of  pyelonephritis.  Thus  I  have  seen 
a  case  of  cystitis  due  to  direct  extension  of  erysipelas  from  the  vulva. 
Luetscher  ^  reports  cases  due  to  bacillus  lactis  aerogenes  (I  have  seen 
one  such).     Chute  ^  reports  an  infection  due  to  penicilium  glaucum. 

PATHOLOGY 

The  lesions  of  cystitis  are  usually  unevenly  distributed  over  the 
bladder.  Indeed,  in  many  acute  or  mild  chronic  cases  the  lesions  are 
entirely  confined  to  the  neck  of  the  bladder  and  the  trigone.  This  so- 
called  inflammation  of  the  neck  of  the  bladder  is  commonly  due  in  men 
to  some  prostatic  inflammation,  which  latter  must  be  attacked  in  order 
to  cure  the  "inflammation  of  the  neck,"  It  may  be  noted  here  that  in 
every  cystitis,  whether  acute  or  chronic,  the  prostatic  urethra  (and  in 
women  practically  the  whole  urethra)  as  well  as  the  bladder  is  inflamed, 
and  the  vesical  inflammation  is  most  intense  about  the  neck  and  the 
trigone,  unless  some  special  feature  of  the  disease  (tumor,  stone,  pouch) 
produces  a  distinct  focus  of  more  intense  inflammation  elsewhere  in 
the  organ. 

Acute  Cystitis — At  first  there  is  a  sharp  congestion  most  marked 
about  the  trigone  and  the  neck,  or  entirely  confined  to  that  region.  The 
mucous  membrane  is  swollen  and  bright  red  in  color.  The  capillaries 
are  dilated,  the  epithelial  cells  swollen.  Then  the  epithelial  cells  begin 
to  desquamate.  The  angry  crimson  of  the  mucous  membrane  is  blotched 
by  petechiae,  its  gloss  is  lost,  and  here  and  there  vesicles  or  superficial 
abscesses  appear.  After  these  break  minute  ulcers  remain.  If  the 
acute  condition  persists  the  muscular  and  peritoneal  coats  may  become 
infiltrated  (interstitial  cystitis). 

Chronic  Cystitis — The  mucous  membrane  is  irregularly  thickened 
and  dense.  Its  surface  is  rough,  red  in  color,  perhaps  mottled  by 
purple  or  brownish  blotches  left  by  submucous  hemorrhages.  There 
may  be  areas  of  ulceration  and  granulation.  Sometimes  the  granula- 
tions grow  to  be  distinct  little  villosities  several  millimeters  long.  The 
ulcerations  may  extend  deep  into  the  substance  of  the  organ  and  com- 
municate (rarely)  with  abscesses  in  the  muscular  tissue.  In  long- 
standing cases  the  epithelium  may  become  cornified  in  spots,  the  super- 
ficial epithelia  being  replaced  by  dense  shiny  scales  resembling  the 

^Bull.  Johns  HopMns  Hosp.,  Oct.,  1911. 
'Boston  Med.  and  Surg.  Jour.,  Mar.  22^  1911. 


BACTERIAL  CYSTITIS  367 

horny  layers  of  the  slcin  {leukoplakia  vesicae).  The  ulcers  may  be 
coated  with  adherent  phosphates.  Cystitis  cystica  and  cystitis  granu- 
losa (cf.  p.  371)   are  perhaps  the  result  of  chronic  inflammation. 

Gross  Changes  tn  the  Wall  of  the  Bladder. — In  prolonoed 
chronic  cystitis  the  wall  of  the  bladder  becomes  thickened  or  thinned, 
its  cavity  contracted  or  dilated,  its  surface  thrown  into  folds  of  mucous 
membrane  overlying  irregular  interlacing  bands  of  muscle  fiber. 

The  resulting  changes  are  described  as  hypertrophy  (thickening)  or 
atony  (thinning)  of  the  bladder.  Hypertrophy  of  the  bladder  may  be 
concentric  (cavity  contracted)  or  eccentric  (dilated).  The  irregulari- 
ties in  the  bladder  wall  are  spoken  of  as  trabeculae  (trabeculated  blad- 
der) or  diverticulae  (sacculated  bladder)  (p.  538).  Diverticulae  ex- 
tend through  the  entire  thickness  of  the  bladder  wall;  they  are  often 
congenital.  Trabeculation  occurs  in  all  cases  of  prolonged  chronic 
cystitis. 

Microscopic  Changes  in  the  Bladder  Wall. — The  microscopic 
changes  in  the  muscle  of  the  bladder  afflicted  with  chronic  cystitis  have 
been  shown  by  Ciechanowski  to  be  almost  purely  sclerotic  whether  this 
muscle  be  thick  and  apparently  hypertrophied  or  thin  and  manifestly 
atrophied.  When  apparently  hypertrophied  the  increased  thickness  of 
the  bladder  wall  is  only  due  in  very  small  degree  to  actual  muscular 
hypertrophy.  It  is  chiefly  due  to  inflammatory  infiltration  and  sclerosis 
of  the  muscle  as  well  as  of  the  interstitial  tissue  between  the  bundles  of 
muscle  fiber.  The  so-called  ^hypertrophied"  bladder  may  be  as  feeble 
as  the  atrophied  bladder.     The  hypertrophy  is  a  false  hypertrophy. 

The  various  degrees  of  hypertrophy  and  atrophy  are  due  to  the  in- 
terplay of  inflammation  and  retention.  If  the  retention  is  slight  or 
absent  and  the  inflammation  severe,  the  bladder  undergoes  concentric 
hypertrophy.  If  retention  is  marked  and  inflammation  severe,  eccen- 
tric hypertrophy  results.  If  retention  is  marked  and  inflammation 
mild,  dilatation  and  atony  result. 

Pericystitis — The  changes  that  occur  in  the  connective  tissue  sur- 
rounding the  bladder  are  usually  of  a  protective  character.  An  intense 
chronic  cystitis  often  provokes  a  thickening  of  the  perivesical  tissue  and 
of  the  peritoneum.  Less  frequently  a  diffuse  fibrolipoma  occurs,  com- 
parable to  the  perirenal  fibrolipoma,  and,  like  it,  protective  in  char- 
acter. In  such  cases  the  fibrous  masses  may  often  be  felt  through  the 
rectum,  and  I  have  known  them  to  be  mistaken  for  cancer  of  the  pros- 
tate until  cystotomy  showed  the  prostate  to  be  normal  and  the  whole 
bladder  to  be  thickened.  When  there  is  much  pericystitis  the  bladder 
is  usually  found  in  a  state  of  concentric  hypertrophy  with  fibrcnis,  un- 
distensible  walls. 

Suppurative  pericystitis  is  usually  due  to  tranma. 

Abscess. — Abscess  of  the  bladder  is  rare.     Small  abscesses  of  the 


368  CYSTITIS 

mucous  membrane  may  run  their  course  unnoticed.  Abscesses  within 
the  wall  of  the  bladder  may  begin  in  some  infected  interstitial  focus  or 
in  a  pocket  of  the  mucous  membrane.  They  burst  into  the  bladder, 
leaving  deep  necrotic  pockets,  which  may  continue  to  suppurate  indefi- 
nitely, or  lead  to  perforation.  Purulent  venous  thrombosis  has  been 
seen. 

Membranous  Cystitis.^ — Exfoliation  of  the  mucous  membrane,  par- 
tial or  complete,  may  occur  as  the  result  of  an  intense  cystitis  or  of 
trauma.  It  is  rarely  seen  except  as  a  complication  of  prolonged  and 
difficult  parturition,  or  as  a  post  mortem  finding  in  patients  who  have 
died  septic. 

SYMPTOMS 

The  three  accepted  symptoms  of  cystitis  are: 

1.  Pits  in  the  urine  (pyuria). 

2.  Frequency  of  urination. 

3.  Pain;  notably  pain  with  urination. 

But  of  these  only  one — viz.,  pyuria — is  constant.  Pus,  frequency, 
and  pain  may  be  due  to  chronic  posterior  urethritis  without  cystitis  or  to 
pyelonephritis  without  cystitis.  If  the  condition  is  acute,  this  triad 
does  indeed  suggest  cystitis ;  but  chronic  pyuria,  frequejicy,  and  pain,  in 
the  absence  of  retention,  suggest  prostatitis  or  pyelonephritis  rather  than 
cystitis. 

Hematuria  if  solely  due  to  cystitis  is  slight,  even  microscopic,  and 
tends  to  appear  at  the  end  of  urination  (terminal  hematuria). 

Systemic  Disturbance — Though  patients  suffering  from  cystitis 
often  exhibit  such  symptoms  as  chills,  fever,  sleeplessness,  anorexia, 
and  loss  of  flesh  and  strength,  these  symptoms  are  not  directly  referable 
to  the  inflammation  of  the  bladder.  The  febrile  s^miptoms  are  due 
either  to  inflammation  of  the  prostate  or  to  implication  of  the  kidneys, 
and  the  loss  of  appetite,  sleep,  and  strength  is  due  to  the  distressing 
symptoms  of  pain,  dysuria,  and  tenesmus. 


TYPES  OF  THE  DISEASE 

Cystitis  is  not  a  disease.  The  normal  bladder  is  singularly  resistant 
to  infection.  The  trigone  readily  becomes  inflamed  by  extension  of 
inflammation  from  the  urethra  or  the  ureters.  Thus  the  cystoscope 
not  infrequently  reveals  a  trigonitis  of  urethral  origin  in  the  female, 
and  would  reveal  it  far  more  often  in  the  male  did  we  not  fear  to 
cystoscope  patients  during  gonorrhea.  Also  the  inflamed  ureter  mouth 
with  adjacent  trigonitis  is  a  familiar  cystoscopic  picture.     But  even 

^Cf.  O'Neil,  Trans.  Am.  Assn.  Genito-Urinary  Surg.,  1909,  iv. 


TYPES  OF  THE  DISEASE  3G9 

such  inflammations  commonly  remain  localized  and  do  not  properly 
constitute  a  cystitis  unless  retention,  trauma,  stone,  or  tumor  make  the 
bladder  vulnerable. 

Cystitis,  whether  acute  or  chronic,  is  always  a  secondary  infection, 
dependent  upon  something  else ;  we  should  never  think  of  it  as  primary. 
When  we  do  we  are  often  using  the  word  "cystitis"  to  cover  some  im- 
portant pathological  fact  such  as  infection  of  the  kidney.  For  in- 
stance, acute  gonorrheal  cystitis  is  a  matter  of  no  importance;  the  im- 
portant lesion  is  the  acute  gonorrheal  prostatitis.  Acute  postoperative 
cystitis  is  a  matter  of  no  importance;  the  important  thing  is  the  re- 
tention, the  important  inflammation  the  acute  renal  infection.  The 
same  is  true  of  the  colon  cystitides.  The  cystitis  of  childhood,  the  cys- 
titis of  pregnancy,  etc.,  are  usually  nothing  more  than  names  to  hide 
a  renal  infection.  A  study  of  88  cases  of  chronic  cystitis  in  women 
by  G.  G.  Smith  ^  is  excellent  statistical  evidence  to  this  effect. 

Therefore,  let  it  be  understood  that  in  speaking  of  cystitis  we  use 
the  term  with  the  greatest  reserve  and,  though  recogTiizing  that  cystitis 
may,  under  unusual  conditions  or  for  brief  periods  of  time,  exist  as  a 
separate  entity,  we  prefer  to  think  of  it  rather  as  a  lesion  accessory  to  a 
urethritis,  a  prostatitis  or  an  infected  kidney. 

Acute  Cystitis — Acute  cystitis  is  characterized  by  very  frequent 
and  very  painful  urination  both  by  day  and  by  night ;  the  act  of 
micturition  terminates  in  a  series  of  exquisitely  painful  spasms,  efforts 
of  the  inflamed  bladder  to  squeeze  out  a  few  drops  of  urine  more  after 
it  is  actually  empty.  The  urine  contains  pus  and  bacteria,  usually 
blood.  The  blood  may  be  mixed  throughout  the  urine,  or  may  be 
terminal  (a  few  drops  of  almost  pure  blood  coming  at  the  end  of  the 
urinary  stream). 

Such  an  acute  cystitis  is  usually  due  to  the  passage  of  instruments 
(in  which  case,  if  not  complicated  by  retention,  it  subsides  in  the 
course  of  a  few  hours),  to  retention  (p.  297),  to  gonorrhea  (see  p.  171), 
to  tuberculosis  (see  p.  420),  or  to  stone  (p.  405). 

Chronic  Cystitis. — Chronic  cystitis  is,  as  stated  above,  essentially 
secondary  to  some  other  lesion. 

It  may  produce  no  symptoms;  thus  the  patient  with  a  paralyzed 
bladder,  whose  symptoms  are  under  control  by  catheterization,  may  show 
quite  an  intense  cystitis  to  the  cystoscope,  but  have  no  subjective  symp- 
toms whatever.  The  urine  merely  contains  pus;  there  is  no  frequent 
or  painful  urination. 

It  is  characteristic,  however,  that  the  inflamed  mucosa  does  not 
stretch  as  kindly  as  the  uninflamed  bladder,  consequently  the  intervals 
between  urinations  are  usually  short,  and  each  urination  not  free  from 
discomfort,     lliere  is  fre(/uent  and  painful  urination  aivi  pus  in  the 

^Jour.  A.  M.  A.,  December  6,  1913,  Ixi,  2038. 


370  CYSTITIS 

urine.      The  intensity  of  these  symptoms  usually  depends  upon  the 
retention,  stone,  etc.,  causing  the  cystitis. 

We  speak  of  acid  and  of  alkaline  (or  ammoniacal)  cystitis ;  the 
former  is  usually  caused  by  the  bacillus  coli,  and  is  mild,  almost 
symptomless.     The  latter,  usually  caused  by  the  ammoniogenic  pyogenic 


Fig.  70. — Cystitis  Cystica  Adjacent  to  a  Carcinoma  of  the  Bladder. 

cocci  or  proteus,  fills  the  urine  with  ropy  mucopus,  and  is  likely  to 
cause  a  violent  infection  with  great  pain,  great  frequenc}^,  and  the 
passage  of  blood.  Ammoniacal  cystitis  is  uncommon  except  in  the 
presence  of  retention  and  of  stone.  The  same  microorganisms  that  break 
up  the  urea  when  there  is  retention  or  stone  fail  to  do  so  when  these 
conditions  are  relieved ;  the  patient  subsides  into  a  mild  condition  of 
acid  cystitis  in  which  the  pyogenic  cocci  or  proteus  may  nevertheless 
be  found  (p.  319). 

Ulcerative    Cystitis — Inflammatory   ulcers   may   result   from    any 
rather  acute  cystitis;  moreover  the  chronic  lilcer  of  the  vesical  vault 


TYPES  OF  THE  DISEASE  371 

in  young  females  described  by  Ilinincr  (p.  43G)  is  doubtless  inflamma- 
tory in  origin.  Another  type  of  ulcerative  cystitis  due  to  the  pyogenic 
cocci  shows  little  insignificant  superficial  aphthous-looking  ulcers  scat- 
tered about  the  mucous  membrane  of  the  l)ladder.  I  have  seen  tliis  type 
of  inflammation  only  in  women.  It  causes  great  frequency  and  pain, 
and  may  not  be  associated  with  any  generalized  inflammation. 

The  lesion  usually  classified  as  simple  ulcer  of  the  bladder  is  better 
termed : — 

Incrusted  Ulcerations. — Ulcerations  due  to  stone,  to  operation  or 
to  tumor  may  become  incrusted  with  deposits  of  phosphatic  salts. 
Similar  incrustations  occur  spontaneously,  doubtless  as  the  result  of 
severe  chronic  inflammation.  Those  I  have  seen  have  been  situated 
near  the  neck  of  the  bladder,  the  ulcer  itself  consisting  of  a  deep  mass 
of  gTanulation  tissue  occupying  the  whole  thickness  of  the  mucous 
membrane;  exquisitely  sensitive,  bleeding  at  the  slightest  touch,  and 
covered  either  wholly  or  in  part  by  a  thick  and  very  adherent  mass  of 
phosphatic  crystals.  The  ulcer  is  surrounded  by  an  angTy  raised  border 
and  presents  an  appearance  strongly  suggestive  of  malignancy.  The 
symptoms  of  incrusted  cystitis  are  most  severe;  the  patient  passes  off 
small  masses  of  phosphates  from  time  to  time. 

Cystitis  Cystica  and  Granulosa — Cystitis  cystica  and  cystitis  gran- 
ulosa (two  entirely  independent  pathological  conditions)  are  perhaps 
due  to  chronic  inflammation  (Fig.  70). 

They  occur  both  in  the  bladder  and  in  the  kidney  pelvis  and  ureter 
(p.  337);  the  precise  cause  is  unknown;  they  are  usually  associated 
with  slight  pyuria,  and  with  renal  or  vesical  irritation  (frequency  of 
urination).  Sometimes  the  symptoms  due  to  them  are  quite  marked. 
They  may  give  rise  to  long-continued  hematuria. 

Leukoplakia. — This,  like  the  two  conditions  just  mentioned,  may 
occur  in  the  kidney  pelvis  or  in  the  bladder;  it  is  quite  obviously 
due  to  chronic  inflammation  in  the  urinary  organs;  it  does  not  seem 
to  give  rise  to  carcinoma  as  it  does  upon  the  tongue.  It  causes  chronic 
pyuria  with  frequent  and  painful  irritation,  and  perhaps  hematuria. 

Interstitial  Cystitis — Inflammation  of  the  bladder  nmselc  is  the 
result  of  prolonged  retention  or  prolonged  severe  cystitis.  It  cannot 
be  said  to  have  any  clinical  picture,  although  when  the  bladder  is 
greatly  contracted  we  know  that  there  is  interstitial  cystitis. 

Pericystitis. — Adhesive  and  fibrolipomatous  pericystitis  gives  no 
symptoms. 

Suppurative  or  phlei>in()nous  pericystitis  may  resnlt  from  infection 
within  the  bladder  (stone,  diverticulum,  retention  )  or  may  arise  from 
the  adjacent  organs  (appendix,  fallopian  tube,  vns  deferens)  or  from 
trauma  (operation,  fracture  of  the  pelvis,  rupture  of  the  bladder)  or 
from  the  prostate  or  seminal  vesicles.     (Tubercular  pericystitis  is  un- 


372  CYSTITIS 

common.)  The  infection  may  be  localized  in  the  space  of  Retzius 
or  in  the  region  above  the  prostate.  General  symptoms  of  septicemia 
predominate  the  clinical  picture;  a  mass  may  be  felt  above  the  pubes 
or  above  the  prostate,  suggesting  carcinoma. 

The  course  of  the  infection  may  be  acute  with  irregular  tempera- 
ture; very  frequently  it  is  extremely  chronic.  There  is  likely  to  be 
cystitis  as  well.^ 

DIAGNOSIS 

The  diagnosis  of  cystitis  is  meaningless  unless  accompanied  by  a 
diagnosis  of  the  associated  renal  or  urethral  or  prostatic  infection  or 
unless  attributed  to  stone  or  tumor. 

Pyuria  in  the  presence  of  retention  or  bladder  stone  or  tumor  means 
cystitis  and  pyelonephritis  as  well.  The  precise  diagnosis  can  only 
be  made  by  the  cystoscope. 

Cystoscopic  Picture. — Acute  cystitis  shows  a  brilliant  red,  ecchy- 
motic,  ulcerated  mucous  membrane.  Mild  chronic  cystitis  is  character- 
ized by  disappearance  of  the  blood  vessels  that  should  be  seen  coursing 
in  the  mucous  membrane.  When  the  cystitis  is  more  chronic,  the 
mucous  membrane  looks  granulating  and  ulcerated,  and  is  of  a  deep 
red  color. 

Cystitis  cystica  and  granulosa  appear  as  little  rounded  red  dis- 
crete or  agglomerated  bodies,  the  precise  nature  of  which  can  only  be 
distinguished  when  they  are  excised  and  examined  under  the  micro- 
scope. Leukoplakia  appears  as  white,  thick  irregular  patches  (similar  to 
those  seen  upon  the  tongue  and  cheeks)  ;  ulcers  are  readily  recognized, 
incrusted  ulcers  look  distinctly  carcinomatous  and  are  diagnosed  by 
cystoscopic  excision. 

TREATMENT 

Prophylaxis. — Prevention  of  cystitis  is  an  important  element  in 
the  treatment  of  prostatitis,  stricture,  prostatism,  bladder  stone  and 
tumor,  as  well  as  in  every  passage  of  an  instrument  into  the  bladder. 
It  requires  no  special  notice  here. 

Treatment  of  Acute  Cystitis. — The  cause  of  the  inflammation  should 
be  removed  if  possible.  If  not  the  patient  is  put  to  bed,  medicated 
with  balsamic  and  anodyne  (p.  221)  and  with  hot  rectal  irrigations 
(p.  209). 

For  local  treatment  instillations  of  argyrol,  carbolic  acid,  and 
silver  nitrate  may  be  of  use.  The  first  is  sometimes  singularly  sooth- 
ing, and  may  be  repeated  as  often  as  twice  a  day;  20  drops  of  a  20 
per  cent  solution.     If  this  fails,  5  drops  of  2  per  cent  carbolic  may  be 

1  Cf .  Chute,  Boston  Med.  #  Surg.  Jour.,  1909,  clxi,  438. 


TYPES  OF  THE  DISEASE  373 

tried  once.     For  gonorrheal  cases  2  drops  of  a  2  to  4  per  cent  solution 
of  silver  nitrate  is  peculiarly  soothing. 

It  is  scarcely  necessary  to  add  that  none  of  these  remedies  will  be 
efficacious  unless  retention  is  relieved. 

Treatment  of  Chronic  Cystitis.— The  peculiarity  of  chronic  cystitis, 
depending,  as  it  always  does,  upon  some  other  morbid  condition,  renders 
its  special  description  unsatisfactory,  and  begets  a  necessity  for  constant 
reference  to  the  other  affections  which  underlie  it.  A  reference  to  the 
sections  on  those  diseases  with  which  cystitis  is  especially  associated, 
notably  prostatism,  stricture,  and  stone,  will  give  a  better  foundation 
for  treatment  than  anything  that  can  be  said  here. 

In  general,  the  radical  treatment  of  chronic  cystitis  consists  in  re- 
moval of  its  cause.  If  the  cause  is  not  removable,  or  if  it  has  been  re- 
moved, the  treatment  is  palliative.  Attention  to  the  general  health,  the 
urinary  hygiene,  the  condition  of  the  bowels,  and  the  quality  of  the 
urine,  constitutes  the  essential  background,  the  passive  part  of  the  cure, 
as  it  were,  while  the  active  work  is  performed  locally. 

The  Urine  Must  be  Modified. — Its  specific  gravity  should  be 
kept  below  1.020 — below  1.015,  if  possible.  This  object  is  attained  by 
making  the  patient  drink  water.  Some  balsamic  is  administered,  to- 
gether with  an  alkali,  as  in  the  treatment  of  acute  gonorrhea. 

Chronic  ulcerative  cystitis,  due  to  the  pyogenic  cocci,  is  very 
rebellious.  I  have  cured  cases  by  instillations  of  2  per  cent  carbolic 
acid,  by  injections  once  a  day  of  5  c.c.  of  a  culture  of  the  bacillus 
acidophilus,  by  instillations  of  2  c.c.  of  20  per  cent  arg}^rol  once  or 
twice  a  day  and  by  injections  of  acetic  acid  as  strong  as  the  patient 
can  bear  (1 :  500  up  to  1 :  200). 

Incrusted  ulcers  may  be  cured  by  similar  treatment.  I  have  cured 
one  case  by  picking  oft"  the  incrustations  wdth  a  cystoscopic  forceps, 
one  by  curetting  through  the  female  urethra,  followed  by  cystoscopic 
forceps,  two  by  acidophilus  bacillus,  and  one  which  resisted  all  treat- 
ment got  well  spontaneously  with  the  casting  off  of  the  incrustations 
three  months  later.  I  operated  upon  two  cases  suprapubically ;  one 
died  of  hemorrhage,  the  other  relapsed,  and  was  cured  by  the  acidopjiihis 
bacillus. 

Suprapubic  incision  and  curettage  or  excision  of  the  affected  areas 
is  the  only  treatment  for  cystitis  cystica  and  granulosa,  and  for  leuko- 
plakia.    It  is  not  brilliantly  successful. 

Interstitial  cj'stitis,  causing  contraction  of  the  vesical  cavity,  is 
best  treated  by  relieving  the  retention  or  other  cause  of  cystitis;  with 
the  amelioration  of  the  inflammation  the  bladder  is  likely  to  expand 
somewhat.  Mechanical  efforts  to  dilate  the  bladder  are  doomed  to 
failure. 

Suppurative  pericystitis  requires  free  suprapubic  drainage. 


374  CYSTITIS 

The  Local  Treatment  Is  the  Most  Impoetaxt. — This  is  tlie 
active,  efficient  part  of  the  treatment  from  which  a  cure  is  expected; 
it  must  be  systematic  and  intelligent.  The  more  acnte  or  recent  the 
inflammation  the  more  advantage  there  is  in  using  instillations  and  in 
pushing  the  strength  of  the  solution  to  the  limit  of  toleration.  I  have 
had  most  success  with  nitrate  of  silver  and  permanganate  of  potassium. 
Chronic,  long-standing  cases  cannot  be  cured  unless  the  cause  of  in- 
fllammation  is  removed.  Ammoniacal  inflammation  may  sometimes  be 
overcome  by  vigorous  local  treatment,  and  the  attempt  should  always 
be  made,  as  the  patient  is  far  safer  with  chronic  acid  cystitis  than  with 
chronic  alkaline  inflammation. 


CHAPTER    XXXIX 

URINARY  CALCULUS :  VARIETIES— ETIOLOGY— TREATMENT 
OTHER  THAN  RADICAL 


A  UKiNAEY  stone,  or  calculus,  is  a  body  resembling  a  stone  in  its  gen- 
eral characteristics,  and  formed  of  crystalline  urinary  salts  (exception- 
ally of  other  substances)  held  together  by  viscid  organic  matter,  and 
showing,  microscopically  or  to  the  naked  eye,  a  laminated  structure. 


Fig.  71. — Section  of  a  Phosphatic 
Calculus,  Showing  Excenteic 
Development. 


Fig.  72. — Uric  Acid  Calculus 
(Section).  The  marked  cen- 
tral lamination  suggests  a  pre- 
ponderance of  uric  acid,  while 
the  more  amorphous  periphery 
shows  an  intermixture  here  of 
urates. 


True  calculi  are  composed  of  a  nucleus,  single  or  multiple,  and 
layers  more  or  less  concentric  of  the  same  or  of  another  material  ar- 
ranged around  it  (Figs.  Yl,  72,  Y3).  This  is  the  case  for  large  as  well 
as  for  microscopic  calculi,  even  for  those  requiring  a  magnifying  power 
of  250  diameters  (Beale)  to  make  out  their  lamination.  Tliis  fact  of 
lamination  alone  differentiates  calculus  from  gravely  the  latter  being 
crystalline  dust  or  concretions  of  crystals  not  showing  definite  structural 
arrangement. 

The  organic  matter  is  usually  quite  overshadowed  by  the  crystal- 
line deposit.    But  exceptionally  the  organic  matter  (blood  clot- or  fibrin) 

375 


376 


URINARY  CALCULUS 


predominates.^  The  stone  still  shows  laminae,  and  salts  (usually  cal- 
cium phosphate),  but  has  the  consistency  of  soft  rubber.  Such  stones 
(called  fibrinous,  colloid  or  blood  calculi)  are  intermediary  in  type 
between  the  familiar  hard  calculus  and  the  unorganized  masses  of 
crystals  and  fibrin  sometimes  found. 

The  nucleus  of  a  stone  may  consist  of  whatever,  among  the  organ- 
ized, crystalline,  or  earthy  constituents  of  normal  or  pathological  urine, 
i^  capable  of  concreting  into  a  more  or  less  solid  mass ;  or  it  may  be  a 
foreign  substance  either  coming  from  within  the  body  or  introduced 
from  without.  The  nucleus  is  usually  in  the  center  of  the  stone  (Figs. 
'72,  Y3).    An  unusual  excentric  development  is  shown  in  Fig.  71. 

The  calculus  takes  its  distinguishing  title  from  the  salt  or  salts 
which  enter  chiefly  into  its  composition. 

VARIETIES 


The  more  refined  and  obscure  points  relative  to  the  varieties  of  stone 
and  their  pathogenesis  cannot  be  dwelt  upon  here.     My  father  consid- 


FiG.  73. — Section  of  Calculus  of 
Mixed  Uric  Acid  and  Oxalate  of 
Lime,  Coated  with  Phosphates. 
Such  a  stone  would  pass  for  phos- 
phatic  on  inspection. 


Fig.  74. — Multiple  Phosphatic  Cal- 
culi (Natural  Size).  The  irregular 
shape  is  due  to  friction.  (There 
were  six  similar  stones  in  t'  is  case). 


ered  the  subject  at  length  in  another  place.^    All  stones  came  under  one 
of  the  following  groups  : 

*Cf.  Gage  and  Beal,  Ann.  Surg.,  1908,  xlvii,  378. 

'Internat.  Encycl.  of  Surgery  (Ashhurst),  vol.  vi.  p.  145. 


VARIETIES 


377 


Fig.  75. — Oxalate 
(Mulberby)  Cal- 
culus. 


are    commonly 


Primary  stone,  which  develops  in  an  acid  urine  without  any  ante- 
cedent inflammation,  may  consist  of  uric  acid,  urate  of  soda,  lime,  or 
potash,  oxalate  of  lime,  cystin,  xanthin,  carbonate  of  lime,  crystalline 
phosphate  of  lime,  or  indigo. 

Secondary  stone,  which  develops  in  an  alkaline  urine  as  the  result  of 
inflammation,  may  consist  of  am- 
moniomagnesium  phosphate  (triple 
phosphate),  amorphous  phosphate 
of  lime,  tricalcic  phosphate,  urate 
of  ammonia,  or  urostealith. 

Among  the  primary  stones  only 
those  composed  of  uric  acid,  ox- 
alate of  lime,  and  urates  are  com- 
mon; the  other  varieties  are  ex- 
tremely rare.  Secondary  stones 
formed  of  mixed  phosphates,  very  rarely  of  urate  of 
ammonia  or  urostealith.  Primary  calculi  are  usually 
formed  of  the  same  substance  throughout,  while  sec- 
ondary phosphatic  calculi  are  often  formed  about  a 
primary  stone  as  a  nucleus. 

The  color  of  stone  is  that  of  its  crystals  modified 
by  blood  piginent.  Thus  the  smooth  mucus-covered 
phosphatic  stone  remains  white,  but  the  rough  oxalate 
stone  usually  loses  its  original  color  and  becomes 
brownish. 

The  form  of  a  stone  depends  upon  various  circum- 
stances, as  illustrated  herewith.  If  fixed,  it  takes  the 
shape  of  the  cavity  in  which  it  lies.  If  movable,  it  is 
ovoidal.  If  in  contact  with  another  stone  it  is  faceted. 
^Numerous  small  stones  lying  in  contact  are  faceted  or 
spheroidal. 

Uric  Acid — Uric  acid  stone  is  found  in  80  per 
cent  of  all  stones.     It  is  usually  mixed  intimately  or 
ones.  These  small    in  layers  with  urates  and  oxalate  of  lime.     Its  color 
ScrnffrLlZ-    varies  from  a  light  fawn  to  a  dark  brown,  in  propor- 
tion, tion  to  the  admixture  of  blood  and  oxalates.     When 
cut  and  polished  it  resembles  an  agate,  displaying  a 
concentric  arrangement  of  irregularly  curved  lines  of  slightly  varying 
color  and  thickness  (Fig.  73). 

The  "urate"  stone,  comparatively  light  in  color  and  soft  \a  con- 
sistency, is  composed  of  a  mixture  of  uric  acid  and  urates.  This  type 
of  stone  is  common  in  the  bladder,  rare  in  the  kidney  and  ureter. 

Oxalate. — Oxalate  of  lime  stone  is  commonly  single,  blackish-brown 
in  color,  and  very  hard.     It  is  usually  covered  with  blunted  asperities, 


Fig.  76. — Multiple 
Small  Phosphatic 
Calculi  (Natural 
Size)  These  stones 
are  selected  from  a 
group  of  33  similar 


378  URINARY  CALCULUS 

whence  it  has  acquired  the  name  of  mulberry  calculus  (Fig.  75).  Upon 
section  it  shows  undulating  laminae,  which  may  vary  widely  in  color, 
as  there  is  often  an  admixture  of  uric  acid  (Fig.  72). 

Phosphate. — Mixed  phosphate  calculus  is  the  common  secondary 
calculus.  It  may  grow  to  an  enormous  size,  and  may  be  single  or 
multiple  (Figs.  73,  74,  76).  It  forms  around  a  primary  calculus,  a 
blood  clot,  or  a  foreign  body.  It  is  granular,  soft,  light  in  weight,  and 
of  a  dirty  white  color.     It  may  be  amorphous  or  laminated. 

The  other  forms  of  calculi  are  so  rare  as  to  require  no  special  men- 
tion. Cystinuria  has  a  medical  rather  than  a  surgical  interest.  Xan- 
thin  ^  is  even  rarer.  I  have  removed  one  cystin  and  one  uric  acid  and 
xanthin  calculus. 

ETIOLOGY 

The  causes  of  stone  formation  are  extremely  obscure.  Secondary 
(phosphatic)  stones  are  known  to  result  from  the  changes  in  the  urine 
commonly  known  as  alkaline  fermentation.  Such  calculi  are  frequent 
in  old  men  suffering  from  the  cystitis  of  prostatism,  and  are  less  fre- 
quently met  with  as  the  result  of  other  forms  of  inflammation. 

But  the  etiology  of  primary  calculus  is  most  obscure.  Primary 
stones  are  very  uncommon  in  women.  The  negro  is  said  to  be  singularly 
exempt,  and  there  are  'two  periods  of  life  during  which  they  are  most 
frequently  found — viz.,  in  the  first  two  and  in  the  fifth  decades  of  life. 
But  the  most  notable  feature  of  the  occurrence  of  primary  stone  is  its 
great  frequency  in  certain  localities  and  its  comparative  rarity  in  others. 
Thus  India  leads  the  list  with  hundreds  of  operations  a  year.  Egypt 
perhaps,  comes  second,  and  North  America  is,  as  a  whole,  comparatively 
exempt.  Yet  in  certain  parts  of  India  primary  calculus  is  quite  as  rare 
as  it  is  with  us,  and  it  has  also  been  observed  that  the  tendency  to  stone 
among  the  inhabitants  of  a  certain  district  seems  to  increase  or  decrease 
regularly  over  a  long  period  of  years.  To  explain  these  vagaries  various 
theories  have  been  adduced.  The  influence  of  the  climate,  the  soil,  the 
water,  the  civilization  of  the  inhabitants  (as  affecting  their  occupa- 
tions), the  diet,  especially  the  amount  of  salt  habitually  taken — all  of 
these  and  various  other  factors  have  been  implicated. 

There  is  some  evidence  of  a  hereditary  tendency  to  stone  foi*mation 
closely  allied  to  the  uric  acid  diathesis.  Indeed,  the  predisposing  cause 
of  primary  stone  is  undoubtedly  the  presence  of  crystals  in  the  urine. 
Without  crystals  there  can  be  no  calculus,  yet  the  urine  may  contain 
crystals  for  years  and  no  stone  form.  A  notable  example  is  the  plios- 
phaturja  so  common  in  the  young.  It  may  continue  for  years,  and  the 
urine  may  be  so  thick  with  phosphates  that  the  terminal  drops,  if  they 

'  A^.  Y.  Med.  Jour.,  Jan.  16,  1915,  p.  120. 


PREVENTIVE  AND  SOLVENT  TREATMENT  OF  CALCULUS  379 

fall  upon  the  patient's  shoe,  give  the  effect  of  a  splash  of  mortar.  Yet 
phosphatic  stone  is  never  due  to  this  phosphaturia.  In  point  of  fact,  the 
microsco]3e  reveals  that  a  urinary  calculus  is  made  up,  not  of  the  sharp- 
pointed  crystals  so  commonly  seen  in  the  urine,  but  of  rounded  masses, 
showing  neither  angles  nor  polarity,  and  consisting  of  an  amorphous 
collection  of  granules  of  a  urinary  salt  embedded  in  a  structureless,  albu- 
minous substance.  If  true  crystals  appear,  they  occur  simply  as  foreign 
bodies  entrapped  in  the  stone.  Rainey  and  Ord  have  conclusively  shown 
that  the  determining  cause  of  calculus  is  the  increased  density  of  the 
urine  and  the  presence  of  colloid  substances  in  solution,  in  conjunction 
with  an  excess  of  urinary  salts;  for  "a  crystalloid  is  deposited  from 
solution  in  the  presence  of  a  colloid,"  and  crystals  introduced  into  a 
colloidal  solution  are  disintegrated  and  reformed  by  simple,  molecular 
coalescence.^  Thus  the  nucleus  of  a  stone  is  always  laid  down  in  an 
albuminous  substance.  A  blood  clot,  a  foreign  body  surrounded  by  the 
mucopus  stirred  up  by  its  presence,  or  the  mucoid  exudate  of  a  mild 
infection  may  form  this  nucleus.  And  once  the  nucleus  has  formed,  it 
is  always  in  such  a  foreign  body  surroitnded  by  albuminous  matter  that 
new  layers  of  stone  are  constantly  being  formed. 

The  rate  of  gTowth  of  a  stone  must  vary  greatly.  Thus  it  is  known 
that  phosphatic  stones  grow,  as  a  rule,  much  faster  than  primary  ones, 
and  yet  my  father  removed  a  uric  acid  calculus  weighing  2  ounces  from 
a  boy  nine  years  old,  and  a  hairpin  from  a  girl's  bladder  (in  which  it 
had  remained  for  more  than  a  year) ,  which  was  incrusted  with  less  than 
a  dram  of  phosphates. 

But  the  practical  problem  in  the  etiology  of  stone  is  not  "Why 
does  stone  form  ?"  but  "Why  is  stone  retained  ?"  If  every  stone  were 
passed  as  soon  as  it  is  formed,  renal  colics  would  be  even  more  common 
than  they  are ;  but  renal  calculus  would  not  be  a  surgical  disease.  The 
fomiation  of  stone  we  can  do  little  to  prevent.  The  retention  of  stone 
is  in  large  part  under  our  control. 


PREVENTIVE  AND  SOLVENT  TREATMENT  OF  CALCULUS 

Inasmuch  as  the  discovery  or  passage  of  a  single  stone  suggests  the 
possibility  that  others  may  be  present  or  may  subsequently  form,  every 
case  of  urinary  calculus  presents  the  problem  of  how  to  prevent  the  re- 
currence of  stone,  while  many  patients,  moved  by  the  blazon  of  the 
Buffalo  lithia  bottle,  inquire,  "IIow  shall  I  dissolve  my  stone?" 

As  an  elementary  proposition,  we  may  state  that  urinary  calculus 
cannot  be  dissolved.  Unless  it  is  passed  it  must  be  removed.  Spon- 
taneous fracture  will  not  help  matters. 

^  Scha.de,  Muench,  med,  Wochenschr.,  Apr.  4,  1911. 


380  URINARY  CALCULUS 

But  medical  aids  may  very  properly  be  invoked  under  two  con- 
ditions : 

1.  To  aid  the  passage  of  a  small  ureteral  stone  (p.  400). 

2.  To  prevent  recurrence  of  stone  after  all  calculi  have  been  passed 
or  removed. 

"No  treatment  can  guarantee  success  in  either  event,  but  treatment 
should  be  conducted  along  the  following  lines : 

Secondary  Stoiie — For  the  prevention  of  secondary  stone  we  de- 
pend upon  the  cure  or  control  of  the  inflammation  causing  it. 

Primary  Stone — The  treatment  includes: 

1.  Relief  of  retention. 

2.  Dietetics — exercise — encouraging  elimination  by  other  avenues. 

3.  Diluting  the  urine. 

4.  Specifics. 

1.  Relief  of  Retention. — In  the  past  our  attention  has  been 
centered  upon  more  or  less  futile  attempts  to  prevent  the  formation  of 
stone.^  The  future  will  see  more  attention  paid  to  attempts  to  prevent 
the  retention  of  stone.  For,  as  stated  above,  stone  formation  is  of  small 
importance  as  compared  with  stone  retention,  l^o  diet,  medicine  or 
mode  of  life  is  guaranteed  to  prevent  the  re-formation  of  stone.  But 
good  surgery  may  often  guarantee  the  prompt  passage  of  any  stone 
that  does  re-form,  and  may  thus  solve  the  problem  of  the  patient's 
cure. 

The  details  of  the  relief  of  retention  are  dealt  with  specifically  for 
each  type  of  stone. 

2.  Hygiene. — Hygiene  and  mode  of  life  have  nothing  to  do  with 
the  cure  of  phosphatic  stone,  since  this  is  secondary  to  infection,  nor 
with  the  amorphous  urate  stone  for  this  will  inevitably  recur  in  the 
bladder  unless  relief  is  afforded  to  the  retention.  Hygiene  relates  only 
to  the  oxalate  stones  that  form  in  the  kidney. 

The  two  gTeat  stone  forming  periods  for  oxalates  are  intra-uterine 
life,  and  perhaps  early  infancy,  and  the  years  between  thirty  and  fifty. 
Why  oxalate  stones  should  prefer  these  periods  is  not  quite  clear.  They 
might  perhaps  be  called  sedentary  (though  mothers  and  golfers  would 
deny  that) .  The  two  factors  of  the  greatest  importance  are,  on  the  one 
hand,  an  excessive  nitrogenous  intake,  and  on  the  other  hand,  an 
excretory  sluggishness,  perhaps  an  actual  retention  of  urine. 

The  fetus  we  cannot  reach.  But  the  middle-aged  patient  begins 
to  have  renal  colic  during  the  time  when  he  is  exchanging  tennis  for 
golf  or  giving  up  exercise  altogether,  really  settling  down  to  the  hard 
struggle  of  self-support,  or  the  even  sterner  struggle  for  success,  is 
likely  to  smoke  too  much,  to  drink  too  much  whiskey  and  too  little  water, 

^  Thus  Eosenbloom  (Jdur.  A.  M.  A.,  July  10,  1915)  observes  that  though  urates 
are  more  soluble  in  alkalies,  oxalates  are  more  soluble  in  an  acid  medium. 


PREVENTIVE  AND  SOLVENT  TREATMENT  OF  CALCULUS     381 

to  overeat,  to  be  mildly  constipated,  perhaps  to  show  indican  and  a  high 
•  blood  pressure.  Such  a  man  requires  exercise.  Exercise  is  the  use 
of  the  muscles  in  the  open  air,  in  an  enjoyable  fashion,  so  violently  as 
to  cause  perspiration.  His  diet  should  be  low  in  nitrogen ;  alcohol,  tea, 
coffee  and  tobacco  should  be  used  sparingly,  and  his  bowels  should  be 
kept  freely  open. 

3.  DiLUTio]\"^. — The  difficulty  with  all  the  above  restrictions  is 
that  they  are  not  for  three  months,  but  for  twenty  years.  Unless  they 
are  prescribed  with  a  very  clear  understanding  of  the  patient's  person- 
ality they  are  futile.  On  the  other  hand,  the  patient  is  usually  quite 
willing  to  return  twice  a  year  for  urinalysis.  Advantage  may  be  taken 
of  this  to  insist  that  he  drink  enough  water  to  keep  the  specific  gravity 
of  the  urine  down  to  or  below  1.015.  So  long  as  this  is  done  the  likeli- 
hood of  stone  formation  is  relatively  slight.  Patients  who  have  diffi- 
culty in  keeping  the  urine  thus  diluted  will  be  much  assisted  by  an 
occasional  course  at  a  diuretic  or  cathartic  mineral  spring.  The  English, 
than  whom  one  could  not  ask  for  better  authority  upon  such  a  sub- 
ject, show  a  strong  preference  for  Contrexeville  and  Carlsbad.  French 
Lick  in  Indiana  is  of  benefit  to  many  persons. 

4.  Specifics. — Specifics  for  stone  appeal  so  little  to  the  modern 
mind  that  it  seems  scarcely  worth  while  to  enumerate  them.  Casper  ^ 
advocates  the  use  of  glycerin  in  tablespoonful  doses,  both  to  prevent  the 
formation  of  calculi,  and  to  favor  their  passage. 

^Med.  Klin.,  October  6,  1915,  eiii,  1611. 


CHAPTER   XL 


RENAL  AND  URETERAL  CALCULUS 


Calculi  occupying  the  kidney  pelvis  or  calices  are  spoken  of  as 
renal ;  those  occupying  the  ureter  are  called,  ureteral  calculi.  All  ure- 
teral calculi  are  actually  renal  calculi  that  have  slipped  down  from  the 
pelvis  of  the  kidney  and  caught  in  the  ureter.  A  large  proportion  of 
vesical  calculi  originate  in  the  kidney. 

Renal  calculi  are  usually  single.     Exceptionally  a  great  number  of 

stones  are  found.  Thus  Mor- 
ris removed  200  stones  from 
one  kidney  and  Dessirier  and 
Legrand  found  400  calculi  in 
the  left  kidney  and  60  in  the 
right  at  the  autopsy  of  a 
young  soldier  v^^ho  during  life 
had  shown  no  symptoms  ref- 
erable to  the  kidneys.  Renal 
calculi  run  up  to  about  100 
grams  (3  ounces)^  in  weight, 
the  large  stones  being  irregu- 
larly branched  to  fit  into  the 
distorted  and  dilated  pelvis 
and  calices  (Figs.  33,  34,  35 
and  11).  In  operating  upon 
a  suppurating  or  tuberculous 
kidney  one  occasionally  meets 
with  very  small  stones,  scarce- 
ly more  than  phosphatic  grit. 
Fibrinous  calculi  are  also 
sometimes  encountered. 

Kraft  found  renal  calculi 
40  times  in  2,953  autopsies; 
both  kidneys  were  affected  15  times.  Legiieu  and  Albarran  agree  that 
in  about  half  the  cases  both  kidneys  contain  calculi,  yet  recent  x-ray 
investigations  go  to  show  that  in  the  living  the  proportion  of  bilateral 
cases  is  not  so  great. 

^Watson  and  Cunningham  depict  a  calculus  that  weighed  one  and  a  half  pounds. 

382 


Fig.  77. — Large  Branched  Renal  Calculus. 


PATHOLOGY  383 

Ureteral  calculi  are  ovoidal  in  shape.  If  multiple  and  in  contact 
they  are  faceted,  but  tliej  are  almost  always  elongated  in  one  diameter 
and  therefore  do  not  throw  a  round  shadow  under  the  llontgeu  ray,  a 
fact  of  great  importance  in  the  study  of  such  shadows  (PI.  IV). 

Ureteral  stones  are  usually  unilateral,  single,  ovoidal,  small.  Most 
exceptional  are  such  stones  as  those  removed  by  Fedoroft"  (length  19 
cm.,  wt.  52  gm.),  Bloch  (length  13  cm.,  wt.  54  gTQ.),  and  Jacobs  (length 
Y.5  cm.,  wt.  44  gm.). 

The  relative  frequency  of  renal  and  ureteral  calculi  is  still  a  ques- 
tion for  dispute.  In  the  preradiographic  period  the  preponderance  of 
renal  over  ureteral  calculi  was  notable.  Today  the  radiographer  finds 
most  calculi  in  the  ureter.  Thus  Leonard  ^  found  calculi  e36  times  in 
the  renal  pelvis  against  70  times  in  the  ureter. 

The  x-ray  catches  the  stone  in  transit,  as  it  were,  for  all  renal  and 
ureteral  stones  originate  in  the  renal  pelvis,  and  of  those  seen  by  the 
radiographer  in  the  ureter  the  greater  number  (31  out  of  Leonard's  46 
cases)   are  passed  spontaneously. 

The  points  in  the  ureter  where  a  calculus  is  most  likely  to  be  caught 
are  (with  percentages  given  by  Jeanbran)  :^ 

1.  One  to  two  cm.  below  the  renal  pelvis  (46  per  cent). 

2.  At  the  lower  end  of  the  ureter,  within  its  ultimate  10  cm.  (51 
per  cent),  less  often  in  its  course  through  the  bladder  wall  (17  per 
cent). 

3.  Rarely  at  or  above  the  pelvic  brim  (15  per  cent). 


PATHOLOGY 

The  changes  that  occur  in  the  kidneys  and  ureters  from  the  presence 
of  calculi  may  be  considered  under  three  heads — -viz.,  retention,  ulcera- 
tion, and  inflammation. 

Retention — A  calculus  formed  in  the  renal  pelvis  may  at  any  mo- 
ment slip  down  and  be  caught  at  the  orifice  of  the  ureter,  or  at  any 
physiological  or  pathological  narrowing  in  that  duct.  Such  an  impac- 
tion may  be  partial  or  complete.  It  is  usually  partial,  and  as  the  urine 
dammed  up  behind  this  sudden  obstacle  brings  pressure  upon  it,  the 
stone  is  forcibly  driven  into  the  ureter,  setting  up  a  renal  colic:  This  is 
relieved  by  the  passage  of  the  stone  into  the  bladder,  by  its  slipping  back 
into  the  pelvis,  or  by  the  gradual  accommodation  of  the  parts  to  the  new 
conditions.  If  the  stone  remains  impacted  it  causes  either  partial  re- 
tention resulting  in  hydronephrosis,  or  complete  retention  resulting  in 
an  acute  anuria  and  subsequent  atrophy  of  the  kidney  (unless  the  ob- 

^Jour.  Am.  Med.  Assn.,  1907,  xlix,  1094,  and  iUd.,  1909,  lii,  289. 
*  Trans.  French,  Urol.  Assn.,  1909,  xiii. 


384 


RENAL  AND  URETERAL  CALCULUS 


struction  is  relieved).  This  complete  retention  is  evinced  by  anuria — 
calculous  anuria  it  is  called — which  is  partial  or  temporary  if  the  oppo- 
site kidney  is  able  to  continue  its  functions,  permanent  and  fatal  if  the 
opposite  kidney  stops  secreting,  whether  on  account  of  reflex  congestion 

or  of  bilateral  calcu- 
lous obstruction. 

Ulceration. Ul- 
ceration occurs  at 
whatever  point  in  the 
kidney,  the  pelvis,  or 
the  ureter  a  stone 
may  rest.  If  the 
stone  is  small  and 
movable  the  ulcera- 
tion may  be  insignifi- 
cant. If  it  is  large 
or  impacted,  the  ul- 
ceration may  be  so 
deep  and  extensive 
that  actual  perfora- 
tion occurs,  permit- 
ting the  stone  to  es- 
cape from  the  kidney 
(the  pelvis  or  the 
ureter)  into  the  sur- 
rounding tissues. 
This  complication, 
associated  as  it  is 
with  urinary  extrava- 
sation, is  as  unusual 
as  it  is  grave.  Ure- 
teral stricture  results 
from  calculous  im- 
paction. 

Inflammation. — It 
is  futile  to  attempt  to 
enumerate  the  various  lesions  that  may  be  caused  by  one  or  more  stones 
in  the  various  portions  of  the  upper  urinary  tract.  The  lesions  of  re- 
tention, ulceration,  and  inflammation  are  combined  in  endless  variety. 
There  may  be  only  localized  suppuration  about  a  small  pelvic  calculus, 
or  there  may  be  numerous  calculous  pockets  throughout  the  kidney ;  the 
entire  organ  may  be  reduced  to  a  multilocular  abscess  cavity  filled  by  a 
great  branching  stone  (Fig.  Y8).  The  kidney  may  be  found  atrophied, 
and  closely  contracted  around  a  stone  that  had  caused  complete  obstruc 


Fig.  78. — Kidney  Destroyed  by  Large  Branching  Silent 
Calculus.  The  patient  had  pus,  frequency  and  tubercle 
bacilli.  Nephrectomy  for  tuberculosis  revealed  this  stone 
and  a  few  minute  tuberculous  lesions. 


SYMPTOMS  385 

tion  years  before.  Pyonephrosis  results  from  obstruction  of  the  ureter 
by  stone  or  stricture  when  there  is  infection.  Suppuration  within  the 
organ  may  be  associated  with  perinephritis  from  extension  of  the  in- 
flammation or  from  rupture  of  the  sac.  The  ureter  shows  various  de- 
grees of  dilatation,  ureteritis  and  periureteritis.  The  longer  the  dis- 
ease continues  the  more  extensive  the  destruction  of  renal  tissue  and 
the  greater  the  likelihood  of  bilateral  calculous  disease. 

The  Ureter. — The  relations  of  stone  and  ureter  are  four,  viz. : 

1.  The  stone  is  simply  in  transit.  It  may  catch  from  time  to  time, 
causing  renal  colic  and  perhaps  slight  temporary  ureteritis  and  dilata- 
tion; but  ultimately  passes  and  leaves  no  permanent  change  in  the 
canal. 

2.  The  stone  is  definitely  arrested.  The  ureter  above  it  is  dilated, 
about  it  ulcerated,  below  it  strictured.  The  stone  may  be  relatively 
movable  (at  operation)  or  fixed.  As  it  grows  it  may  become  encysted 
in  a  pocket  in  the  ureter  wall. 

3.  The  ureter  ruptures  (a)  by  acute  gangrene,  or  (b)  ulceration 
about  an  encysted  stone.  The  result  is  usually  acute  retroperitoneal 
phlegmon,  infiltration  of  urine,  abscess,  fistula.  Rarely  an  encysted 
stone  escapes  silently  into  the  retroperitoneal  tissue.^ 

4.  The  ureter  is  so  dilated,  the  stone  so  smooth  and  small,  that  the 
latter  slips  readily  to  and  from  the  pelvis,  up  and  down  the  ureter. 

Carcinoma.^ — I  have  seen  two  cases  of  renal  carcinoma  secondary 
to  stone.     Coryell  ^  reports  nine  such  cases. 
Tuberculosis. — See  Fia;.  78. 


SYMPTOMS 

Renal  calculus  may  exist  for  years  without  causing  any  symptoms 
whatever.  Morris  mentions  the  notable  symptoms  caused  by  renal  cal- 
culus in  103  cases  of  his  own.     These  he  tabulates  as  follows : 

Pain   occurred   in    ' 71  cases  (69  per  cent). 

Pyuria   occurred    in    50     "      (48  per  cent). 

Renal  colic  occurred  in 44     "      (43  per  cent). 

Hematuria  occurred  in 41     "      (40  per  cent). 

Kidney  palpably  enlarged  in 27     "     (26  per  cent). 

Troubles  of  micturition  occurred  in.  .  24     "      (23  percent). 

Pain. — Of  calculous  diseases,  Morris  writes:  "They  are  the  most 
frequent  and  most  painful  of  surgical  diseases  of  the  kidney.     Probably 

^  Cf.  Frenkel,  Guyon's  Annalcs,  xxix,  p.  1825. 

^  Bull.  J.  HopMns  Hospital,  April,  1915,  xxvi,  93. 


^ 


386  RENAL  AXD  URETERAL  CALCULUS 

no  disease,  except  acute  tetanus,  is  capable  of  causing  worse  suffering." 
The  various  pains  due  to  renal  and  ureteral  calculi  are  renal  colic,  pres- 
sure pains,  and  reflex  pains. 

Eenai.  Colic. — This  is  the  most  characteristic  symptom  of  stone  in 
the  kidney.  It  is  due  to  the  impaction  of  a  stone  in  the  ureter.  The 
pain  is  paroxysmal  in  character.  It  commences  suddenly  in  the  loin  or 
side,  at  any  time,  when  the  patient  is  seemingly  in  the  best  of  health. 
It  shoots  down  the  ureter  into  the  scrotum  and  to  the  end  of  the  penis. 
The  testicle  of  the  affected  side  is  often  strongly  retracted.  Indeed, 
the  entire  scrotum  and  penis  may  be  drawn  up  into  a  hard  knot,  as  it 
were.  The  pain  may  also  extend  down  the  thigh  on  the  affected  side. 
There  may  be  an  incessant  desire  to  pass  water.  What  little  urine 
is  voided  comes  away  high-colored  and  tinged  with  blood.  If  the 
paroxysm  is  severe,  faintness,  nausea,  and  vomiting  occur,  the  skin 
is  covered  with  a  cold  sweat,  and  the  patient  passes  into  severe 
shock. 

In  the  intervals  between  paroxysms  there  is  a  sense  of  soreness 
and  discomfort  perhaps  amounting  to  continued  pain,  or  the  relief  may 
be  absolute.  After  one  or  more  paroxysms,  lasting  from  a  few  hours 
to  many  days,  all  pain  suddenly  ceases.  This  sudden  cessation  indi- 
cates that  the  stone  has  been  liberated.  It  may  have  fallen  back  into 
the  pelvis  of  the  kidney,  have  passed  down  into  the  bladder,  or  have 
reached  some  dilated  portion  of  the  ureter,  where  it  rests  without  in- 
terrupting the  urinary  outflow. 

If  the  impaction  has  occurred  at  the  upper  end  of  the  ureter  and 
is  relieved  by  the  stone  slipping  back  into  the  pelvis,  the  pain  during 
the  attack  is  usually  most  intense  in  the  loin  and  radiates  across  the 
back  rather  than  down  the  ureter.  On  the  other  hand,  if  the  stone 
travels  down  the  ureter  to  the  bladder,  its  descent  is  often  marked  by 
a  progTession  of  the  pain  from  the  loin  to  the  pelvis — interrupted  by 
periods  of  relative  or  absolute  ease — with  a  corresponding  increase 
in  the  vesical  irritability  and  the  pain  and  retraction  of  the  testicle. 
But  this  relation  of  the  pain  to  the  progress  of  the  stone  has  many  ex- 
ceptions. 

Presstjee  Paixs, — When  the  stone  is  in  such  a  position  or  of  such  a 
size  as  to  fill  the  cavity  in  which  it  lies,  it  may  cause  a  dull  continuous 
ache  associated  with  tenderness.  This  ache  is  rarely  severe;  indeed, 
some  persons  will  endure  it  for  years  without  attaching  any  great  im- 
portance to  it. 

Eeflex  Paixs. — The  two  most  notable  renal  reflex  pains  excited  by 
stone  are:  (1)  Pain  following  the  course  of  the  ureterinto  the  pelvis 
and  thence  radiating  to  the  testicle  and  thigh,  and  (2)  painful  and  fre- 
quent urination. 

I  have  twice  seen  frequent  and  painful  urination  as  the  only  symp- 


COURSE  OF  THE  DISEASE  387 

torn  of  a  stone  filling  the  renal  pelvis.  But  this  symptom  usually  means 
irritation  (stone)  at  the  lower  end  of  the  ureter. 

The  pain  maj^  occasionally  be  felt  only  in  the  "stomach"  and  as- 
sociated with  vomiting.  Or  it  may  be  "sacro-iliac"  or  "lumbago"  in 
type. 

It  is  questionable  whether  stone  in  one  kidney  may  give  pain  re- 
ferred only  to  the  opposite  organ.  This  so-called  "renorenal  reflex"  is 
usually  due  to  hypertrophy  or  disease  of  the  opposite  kidney. 

Hematuria. — As  shown  by  the  table,  considerable  hematuria  is  a 
fairly  constant  symptom  of  stone.  Yet  it  is  variable  to  the  last  degree. 
Some  hematuria  usually  accompanies  and  follows  a  renal  colic,  and  in 
most  cases  there  is  a  fairly  constant  oozing  of  blood,  showing  itself  only 
by  the  presence  of  a  few  red  cells  and  a  trace  of  albumin  in  the  urine. 
Blood  casts  and  long  ureteral  clots  rarely  occur.  The  bleeding  is  usu- 
ally made  worse  by  exercise  (though  the  pain  is  not),  and  hence  the 
presence  of  a  great  number  of  red  cells  in  the  sediment  centrifuged 
from  the  urine  passed  after  exercise  is  suggestive  of  stone.  But,  after 
all,  the  hemorrhage  caused  by  renal  stone  is  an  inconstant  symptom. 
It  may  be  entirely  absent  even  after  a  renal  colic. 

The  remaining  symptoms  on  the  list  require  no  special  notice. 


COURSE   OF  THE  DISEASE 

The  course  of  the  disease  is  entirely  irregular.  The  character  of  the 
symptoms  bears  no  precise  relation  to  the  size  or  position  of  the  stone ; 
and  the  progress  of  the  disease  varies  from  the  cases  that  have  only  a 
single  fatal  attack  of  calculous  anuria  or  that  die  of  some  intercurrent 
disease  without  ever  having  manifested  any  symptom  referable  to  the 
calculi  with  which  their  kidneys  are  filled  to  those  that  drag  on  for 
years  with  chronic  renal  suppuration  and  repeated  passage  of  stone. 

Several  types  of  the  disease  may  be  mentioned,  due  allowance  being 
made  for  the  fact  that  a  given  case  is  often  a  compound  of  several  types. 
The  surgeon  encounters:  (1)  Cases  without  symptoms,  (2)  cases  of 
renal  colic,  (3)  cases  of  calculous  anuria,  (4)  cases  of  renal  distention, 
and   (T))   eases  of  renal  suppuration. 

Cases  Without  Symptoms. — Tlie  onset  of  symptoms  of  renal  cnlcu- 
lus  is  not  the  beginning  of  stone.  When  the  niiinitc  calculus  tirst 
forms  in  the  renal  pelvis  its  place  is  determined  by  the  shape  and 
drainage  of  that  cavity.  If  the  pelvis  is  well  drained  the  urinai-y 
stream  will  sweep  the  little  calculus  into  the  ureter  before  it  has  at- 
tained any  great  size.  It  announces  its  passage  to  the  bladder  by  a 
series  of  renal  colics,  even  though  it  be  extremely  minute,  no  larger 
than  a  grain  of  wheat. 


388  RENAL  AND  URETERAL  CALCULUS 

But  if  the  pelvis  is  not  well  drained  a  stone  naturally  sinks  into 
some  calyx  where  it  slowly  and  silently  grows.  At  most  it  causes  a 
pyuria,  or  a  microscopic  hematuria.  But  since  this  excites  no  sub- 
jective symptoms  it  is  usually  entirely  overlooked.  Such  stone,  if 
actually  silent,  may  be  discovered  only  at  autopsy  or  by  the  investigation 
that  follows  the  disclosure  of  albumin  and  pus  in  the  urine  as  the 
result  of  an  examination  for  life  insurance.  Such  stones  frequently 
grow  quite  silently  until  the  kidney  is  almost  totally  destroyed  and  the 
x-ray  shows  an  enormous  stone  (PI.  VI).  Although  it  is  possible 
for  stone,  even  bilateral  renal  stone,  to  remain  thus  silent  for  twenty 
or  thirty  years  or  longer.  At  the  onset,  or  at  least  during  the  first  five  or 
ten  years  of  the  disease,  small  pieces  of  stone  are  likely  to  descend  into 
the  bladder,  giving  a  history  either  of  renal  colic  or  of  vesical  calculus. 
Later  in  the  disease  the  stone  may  cause  slight,  painless,  protracted 
hematuria.  It  is  very  likely  to  cause  some  disturbance  of  urination, 
and  perhaps  excite  a  great  deal  of  bladder  irritability,  and  when  large 
it  always  causes  pyuria,  albuminuria  and  diminution  of  the  kidney 
function.  If  all  of  these  symptoms  are  either  overlooked  or  misinter- 
preted the  patient  may  be  left  to  die  of  renal  insufficiency  alone  or 
excited  by  some  intercurrent  disease  or  accident  (Fig.  78 ;  also  PI.  VI). 
Renal  Colic. — The  preceding  description  of  the  general  character 
of  the  attack  of  renal  colic  leaves  only  a  few  remarks  to  be  made  upon 
this  subject.  The  course  usually  lasts  only  three  or  four  months  if 
the  stone  is  to  pass.  But  I  have  several  times  known  a  stone  to  pass 
from  the  ureter  after  two  years  of  colics.  Yet  even  when  the  stone 
has  passed,  the  stone-forming  habit  is  likely  to  continue,  so  that  either 
from  the  discharge  of  calculi  collected  in  the  kidney  pelves  above,  or 
from  the  actual  formation  of  new  stones,  the  patient  who  has  once  had 
renal  colics  is  rather  likely  to  have  further  attacks  in  later  years.  In 
one  sense,  however,  renal  colic  with  the  passage  of  stone,  and  no  evi- 
dence of  any  deterioration  of  kidney  function  or  accumulation  of  stone 
left  behind  in  the  kidney  pelvis,  is  a  good  omen,  for  it  means  that  the 
kidney  pelvis  drains  well,  and  that  if  subsequent  stones  do  form  they 
are  likely  to  be  passed  as  was  the  first  one. 

Reflex  Symptoms. — Other  cases  again  give  only  reflex  symptoms. 
One  of  my  earliest  professional  recollections  is  of  an  old  man  who  for 
years  suffered  only  from  painful  and  frequent  urination.  His  bladder 
was  washed,  searched,  sounded,  and  even  cut — all  to  no  avail.  New 
York's  best  surgeons  of  those  days  could  do  nothing  for  him.  Finally, 
his  protracted  agony  was  terminated  by  a  fatal  attack  of  suppression 
of  urine,  as  it  was  called.  Autopsy  revealed  a  normal  bladder  and  one 
kidney  atrophied  and  tightly  contracted  about  a  calculus,  the  other 
somewhat  dilated  and  with  a  stone  plugging  the  ureteral  orifice.  Yet 
he  had  never  complained  of  a  symptom  referable  to  either  kidney. 


COURSE  OF  THE  DISEASE 


389 


Calculous  Anuria. — Calculous  anuria  is  a  stoppage  of  the  urinary 
flow  caused  by  the  plugging  of  one  or  both  ureters  with  calculi.  It  is 
part  suppression,  part  retention.  The  terminal  anuria  in  the  case 
mentioned  above  was  a  pure  retention.  One  kidney  had  been  out  of 
commission  for  years ;  the  flow  of  urine  from  the  other  was  stopped 
by  the  obstructing  stone.  In  other  cases  the  blockage  of  one  ureter 
throws  such  a  burden  of  excretion  upon  the  opposite  kidney  that  it 
becomes  acutely  congest- 
ed, and  suppression  en- 
sues. Thus  anuria  may 
ensTie  (1)  when  both  ure- 
ters are  completely  ob- 
structed, or  (2)  when  one 
ureter  is  obstructed  and 
the  opposite  kidney  ab- 
sent, hypertrophied,  or 
sufficiently  diseased  to  be 
incapable  of  enduring  the 
congestion  forced  upon  it. 
The  acute  obstruction  is 
clinically  unilateral,  but 
unless  both  kidneys  are 
diseased  anuria  does  not 
occur. 

Pathology.  —  The 
pathology  of  calculous 
anuria  is  striking  and 
characteristic.  The  ob- 
structed kidney,  which 
may  be  hydronephrotic 
or  suppurating,  is  in- 
tensely congested.  It  is 
enlarged  to  twice  or 
thrice  its  normal  size  and 
is  dark  in  color.  On  sec- 
tion its  tissues  are  found  friable  and  edematous.  Such  a  large 
purple  organ  once  seen  is  never  forgotten  (Fig.  79). 

The  opposite  kidney  in  all  but  3  of  the  58  cases  collected  by  Morris 
was  absent  or  completely  disorganized. 

Symptoms. — The  symptoms  of  calculous  anuria  may  be  divided  into 
three  stages:  1.  The  premonitory  stage.  2.  Tlie  tolerant  stage.  3.  The 
uremic  stage. 

1.  In  the  premonitory  stage  there  is  more  or  less  pain, "perhaps  an 


Fig.  79. — Calculous  Anuria;  the  Congested  Kidney. 
The  stone  was  impacted  lower  down  the  ureter.  (Com- 
pare Fig.  80 ) 


soft 


390 


EENAL  AXD  UEETEEAL  CALCULUS 


actual  colic,  referred  to  the  kidney. 
few  days. 


It  persists  from  a  few  hours  to  a 


^  A 


Fig.  80. — Calculous  Hydronephrosis. 
A  small  stone  was  found  lodged  at  A. 
This  kidney  is  the  fellow  of  the  one 
shown  in  Fig.  79.  They  were  ob- 
tained from  a  patient  who  died  of  cal- 
-  culous  anuria. 


2.  The  tolerant  stage  is  charac- 
terized hy  but  one  symptom — viz., 
anuria.  The  patient  does  not  pass 
water.  This  anuria  is  rarely  abso- 
lute. A  few  grams  of  urine  tinged 
with  blood  are  passed  every  day,  or 
perhaps  the  anuria  runs  a  remittent 
course.  At  one  time  or  another  2  or 
3  liters  of  urine  may  gush  forth,  a 
misleading  promise  of  relief,  for  the 
flow  is  but  temporary.  This  state  of 
affairs  lasts  from  three  days  to  a 
week.  Xot  a  drop  of  urine  may  be 
fassed  during  several  days  and  yet 
the  patient  may,  apparently ,  remain 
ill  the  best  of  health.  jSTo  more  strik- 
ing contrast  could  well  be  imagined 
than  that  presented  by  calculous  an- 
uria :  on  the  one  hand,  the  grave 
renal  lesion,  the  absolute  retention, 

the  swift  fulminating  character  of  the  uremic  period  soon  to  follow; 

and,  on  the  other  hand,  this  entire  absence  of  symptoms,  local  or  gen- 
eral.       The     patient     goes 

about    well     content.       He 

eats,      sleeps,      and     works 

pretty      much      as      usual. 

Whatever  pain  he  has  had 

in  the  loin  is  past,  and  his 

present  discomforts  are  in- 
significant.      Yet     all    the 

while    there    is    brewing 

within   him    a    crisis    swift 

and  terrible. 

Spontaneous       recovery 

may   occur.      The    obstruc- 
tion is  relieved ;  the  urine 

gushes  out,  3  or  4  liters  a 

day,  and  all  is  well.     This 

may  occur  in  20.8  per  cent 

(Morris)   to  28.5  per  cent 

(Legiieu)  of  cases.    In  Legneu's  ^  cases  the  spontaneous  cure  took  place 
^  Guyon's  Annales,  1895,  xiii,  865. 


Fig.  81. — Calculous  Pyonephrosis.     This  kidney 
contained  the  stone  shown  in  Fig.  77. 


COURSE  OF  THE  DISEASE 


391 


on  the  third  day  once,  between  the  fifth  and  the  tenth  day  twice;  later 
still  in  five  instances.  Yet  it  is  obvious  that  one  should  not  await  spon- 
taneous cure. 

When  spontaneous  recovery  does  not  occur  the  patient  passes  into 
the  third  stage  of  the  disease  at  the  end  of  a  week  or  ten  days. 

3.  The  uremic  stage  is  usually  ushered  in  by  hiccough  or  vomiting. 
This  is  the  first  warning.  It  may  continue  for  a  day  or  two  without 
additional  symptoms.  The  pulse  is  tense,  the  temperature  usually  sub- 
normal. Constipation  becomes  absolute  and  the  intestines  are  distended 
with  gas.      The   vomiting  grows   more   severe,   the  intellect   becomes 


Fig.  82. — Pyelogram  Showj 


l)ii>AriJD  Kidney  and  Ureter  (Pyelonephritis)  After 
Removal  op  Stone. 


dulled  and  stuporous.  The  patient's  mind  may  wander  a  little,  and  he 
may  even  have  maniacal  attacks.  Thus  he  sinks  away  and  dies,  usually 
within  two  or  three  days  of  the  first  hiccough  or  vomiting. 

Such  is  the  clinical  picture  of  what  Morris  has  aptly  termed  the 
gravest  and  most  fatal  of  the  many  serious  complications  of  urinary 
lithiasis.  Of  course  there  are  atypical  cases:  the  obstruction  iniiy  I)e 
intermittent  or  partial ;  l)ut  such  cases  require  no  special  notice. 

Calculous  Hydronephrosis — Calculous  hydronephrosis  is  due  to  the 


392  RENAL  AND  URETERAL  CALCULUS 

mpaction  of  a  stone  in  the  ureter  (Fig.  80),  or  rarely  to  a  stricture  sec- 
ondary to  calculous  ulceration.  The  development  of  the  hydronephrosis 
is  habitually  marked  by  a  series  of  renal  colics,  and  hydronephrosis 
may  be  one  of  the  features  of  calculous  anuria.  The  symptoms  and  signs 
of  hydronephrosis  are  detailed  elsewhere. 

Eenal  Suppuration. — Stone  in  the  kidney  is  one  of  the  most  com- 
mon causes  of  pyelonephritis.  It  also  causes  pyonephrosis  (Fig.  81)  ; 
while  secondary  phosphatic  calculus  or  phosphatic  deposit  upon  a  pre- 
existing calculus  results  from  the  inflammation. 

The  variations  imprinted  upon  the  classical  picture  of  pyelonephritis 
and  pyonephrosis  by  the  presence  of  stone  are  few.  There  are  the  same 
urinary  septicemia,  the  same  local  symptoms.  There  may  be  colic. 
Hemorrhages  occur  from  time  to  time.  The  inflammation  is  rarely 
acute  or  virulent,  but  progresses  slowly,  terminating  finally  in  pyo- 
nephrosis or  perinephritic  abscess. 


DIAGNOSIS 

The  accurate  diagnosis  of  stone  in  the  kidney  pelvis  or  tho  ureter 
must  cover  the  following  points : 

1.  The  presence  or  absence  of  stone. 

2.  The  number,  position,  and  distribution  of  stones. 

3.  The  presence  or  absence  of  renal  infection. 

4.  The  functional  capacity  of  both  kidneys. 

In  order  to  make  this  diagnosis,  familiarity  with  radiography  and 
with  the  methods  of  testing  the  renal  function  is  essential.  Without  the 
x-ray  and  the  ureter  catheter  it  is  possible,  in  certain  cases,  to  diagnose 
the  presence  of  stone  with  some  accuracy  and  to  operate  for  its  relief 
with  some  success ;  but  both  methods  are  necessary  in  order  to  insure 
good  work  in  all  cases,  and  in  order  to  insure  any  diagnosis  at  all  in 
some. 

The  most  typical  history  of  renal  stone,  even  if  accompanied  by 
characteristic  gross  evidences  of  such  conditions  as  pyonephrosis  or  cal- 
culous anuria,  is  not  enough  to  indicate  to  the  surgeon  such  important 
facts  as  the  position  and  number  of  the  stones  present,  or  the  functional 
capacity  of  the  opposite  kidney ;  and  most  cases  first  apply  for  relief 
at  a  time  when  the  history  is  anything  but  characteristic,  the  physical 
signs  anything  but  adequate  to  insure  appropriate  treatment. 

The  following  table,  which  has  been  prepared  by  Dr.  Charles  East- 
mond  as  a  result  of  his  radiographic  experiences,  indicates  quite  ac- 
curately how  often  the  symptoms  and  physical  signs  are  misleading  as 
to  the  presence  or  absence  of  stone.  They  are  still  more  often  mislead- 
ing as  to  the  condition  of  the  kidneys. 


DIAGNOSIS  393 

TOTAL  CASES,  8o|^^^^^."^  P^^^^^*- " '  "^^  =  (28-75%) 
[Negative 57  =  (71.25%) 

With  typical  symptoms  (renal) 8 

(Two  had  additional  calculi  in  opposite  kidney.) 

With  indefinite  symptoms 9 

With  symptoms  on  opposite  side  to  calculus 3 

With  symptoms  referred  to  other  parts 3 

(Of  these,  two  had  renal  symptoms  with  calculi  in  the  bladder;  one 

vesical  symptoms  with  calculus  in  kidney.) 

na^,u,      ■     ^  ,        JcalcuH 14  =  (24.14%) 

58  with  typical  symptoms^     ,     t  •               i.  j        •  o       /io  th/tt 

•^  -^  Lcalcuh  m  suspected  region 8  =  (13.79%) 

22  with  indefinite  symptoms — calcuH 9  =  (40.90%) 


23  cases  of 
calcuU 


23  with 
calculus 


57nega- 
tive 


URINE. 

Pus.  Blood.Both.None.Total 

Typical  symptoms  with  cal-J  +  sand^  11114 
cuU  to  sand     12      0       14 


(34.78%) 


Symptoms  vague  or  referred  I  +  sand     2  1  2  0  ^X-ik  —  /arono/^ 

to  other  points  than  site  I  0  sand  _5  ^  _0  _4  lOJ 

of  calculus                                             9  5  3  6 

'Typical  symptoms —              J  +  sand    3  6  4  5  18\44  —  ('771Qt5''i 

Ocalcuh                           to  sand    5  4  8  9  26r      ^^^^'^''^ 


Vague  symptoms —  J  +  sand    0      3      0      6      ^  1 1  o 

OcalcuU  to  sand  J.     _1     _2    _0     JJ_ 

IS     19     17    26  80 


Our  means  of  diagnosis  may  be  summed  up  under  tlie  following 
heads,  in  the  order  of  their  employment : 

1.  The  patient's  history. 

2.  Physical  examination  and  urinalysis. 

3.  Radiography. 

4.  Substitutes  for  radiography. 

5.  Ureteral  catheterism. 

6.  Exploratory  operation. 

Patient's  History. — The  presence  of  calculus  is  suggested  by  his- 
tory of  the  passage  of  stone,  of  renal  colic,  of  anuria,  or  by  the  pres- 
ence or  history  of  stone  in  the  bladder.  Every  case  of  pyelonephritis  is 
suspected  to  be  calculous  until  the  absence  of  calculus  has  been  proven 
by  radiography.  Yet  how  misleading  the  history  may  be  is  shown  by 
the  table  given  above. 

Physical  Examination  and  Urinalysis. — The  presence  of  stone  in 
the  bladder  or  of  renal  infection  suggests  the  possibility  of  renal  or 
ureteral  stone.  It  is  exceptionally  possible  to  palpate  through  the 
vagina  or  the  rectum  large  stones  incarcerated  at  the  lower  end  of  the 
ureter. 

Urinalysis  suggests  stone  when  crystals  of  uric  acid  or  oxalate  of 
lime  are  present  in  great  numbers,  especially  if  these  are  found  in  the 

^History  or  present  evidence  of  the  passage  of  stone,  gravel,  sand,  or  crystals. 


394  RENAL  AND  URETERAL  CALCULUS 

rounded  forms.  A  relatively  high  percentage  of  urea  in  relation  to  the 
urinary  specific  gravity  is  suggestive  of  stone,  and  the  presence  of  blood 
ceiis  with  crystals  in  the  urine  is  peculiarly  suggestive.  Yet  the  passage 
of  crystals  alone  often  causes  renal  colic  and  may  even  produce  a  macro- 
scopic hemorrhage.  Moreover,  v^hile  the  rule  is  almost  universal  that, 
so  long  as  stone  is  present  in  the  upper  urinary  tract,  there  are  con- 
stantly a  few  blood  cells  in  the  urine,  I  have  known  two  notable  excep- 
tions to  this  rule:  i.  e.,  two  cases  in  which  stone  was  present  but  the 
urine  showed  no  red  blood  cells.  On  the  other  hand,  microscopic  traces 
of  blood  are  constantly  found  in  the  urine  as  a  result  of  so  many  con- 
ditions other  than  renal  stone  that  the  presence  of  blood  cells  alone  is 
no  more  than  suggestive. 

Appendicitis  and  ureter  stone  give,  symptoms  so  closely  simulating 
each  other  that  special  signs,  notably  blood  and  pus  in  the  urine,  have 
been  sought  to  distinguish  them.  But  appendicitis  can  cause  hematuria 
through  involvement  of  the  lower  ureter  in  the  inflammation,  or  by 
causing  toxic  or  bacterial  nephritis.-^ 

The  presence  of  tubercle  bacilli  in  the  urine  does  not  exclude  stone, 
for  secondary  stone  may  form  in  a  tuberculous  kidney. 

Radiography. — A  good  radiograph  is  the  surest  evidence  in  the 
diagnosis  of  renal  and  ureteral  stone.  (Figs.  30  to  35  ;  PL  III  to  VIII). 
For  it  shows  the  size,  shape  and  disposition  of  calculi.  But  an  x-ray 
plate  is  by  no  means  infallible.  It  may  fail  to  show  a  stone,  even  though 
the  plate  be  perfect.  And  it  may  show  shadows  suggestive  of  stone 
when  no  stone  is  actually  present.  Real  familiarity  with  radiography 
is  required  for  the  interpretation  of  plates.  A  few  of  the  elementary 
requisites  are  detailed  in  Chapter  IX,  but  this  real  familiarity  can  only 
be  gained  by  long  experience. 

The  greatest  check  on  the  accuracy  of  radiography  is  to  be  sought 
in  the  evidence  of  renal  insufficiency  and  infection  which  always  re- 
sults from  the  presence  of  large  stones,  and  the  wax-tipped  catheter 
which  confirms  the  presence  of  small  ones. 

The  Wax-tipped  Catheter — The  wax-tipped  catheter  devised  by 
Kelly  consists  of  a  ureter  catheter,  the  tip  of  which  has  been  dipped  in 
melted  dentist's  wax.  This  tip  should  be  carefully  examined  with  a 
magnifying  glass  before  the  instrument  is  introduced,  to  be  sure  it  is 
not  scratched. 

Several  ingenious  devices  have  been  suggested  whereby  the 
wax-tipped  catheter  may  be  introduced  through  the  indirect 
vision  cystoscope  without  scratching  the  wax.  The  simplest  of 
these  is  a  suggestion  of  Harris  that  the  instrument  be  introduced 
first    into    the    bladder,     and    the    cystoscope    threaded    over    this.^ 

^Von  Prisch,  Zeitschr.  f.  Urol.,  1912,  Supplement. 
"Hurg.,  Gyn.  #  Obstet.,  December,  1912,  p.  727. 


DIAGNOSIS  395 

His  description  may  be  paraphrased,  with  slight  modifications,  as 
follows : 

A  filiform  ureteral  bougie  or  ureteral  catheter  no  larger  than  Xo.  4 
size  is  tipped  with  wax,  the  drop  of  wax  being  about  a  ISTo.  G  or  8  F. 
size  (if  this  will  not  enter  the  ureter  orifice  a  wax  spindle  of  about 
the  same  size  rnaj  be  made  at  2  or  3  c.c.  from  the  tip  of  the  filiform). 
The  wax  is  carefully  examined  with  a  magnifying  glass  for  scratches, 
the  filiform  is  then  lubricated,  and  introduced  into  the  bladder,  which 
has  been  previously  filled  with  fluid.  The  distal  end  of  the  filiform  is 
then  threaded  through  the  catheter  sheath,  and  the  cystoscope  is  guided 
over  it  into  the  bladder  just  as  a  tunnelled  sound  is  guided  through  the 
urethra.  When  the  cystoscope  is  introduced  it  is  revolved  in  the  bladder 
until  the  shaft  of  the  filiform  is  seen  lying  fairly  in  front  of  the  lens. 
The  deflector  is  then  raised  so  as  to  fix  it  in  this  position,  and  the 
filiform  slowly  and  cautiously  withdrawn  until  the  wax  bulb  is  seen  in 
the  field.  The  deflector  is  then  lowered,  and  the  wax  again  inspected 
so  as  to  make  sure  it  is  not  scratched.  It  is  then  introduced  into  the 
ureter,  withdrawn,  and  inspected  while  still  in  the  bladder;  the  bulb 
being  revolved  so  that  all  sides  are  seen.  The  wax  tip,  when  lying 
close  against  the  objective  of  the  cystoscope,  is  so  much  magnified  that 
there  seems  no  need  to  withdraw  it  for  examination.  If  it  is  found  not 
to  be  scratched,  it  may  be  introduced  into  the  opposite  ureter,  and  the 
examination  repeated.  The  absence  of  scratches  may  be  verified  still 
further  by  turning  the  lens  upward  in  the  distended  bladder,  pushing 
the  filiform  about  5  or  10  c.c.  into  the  bladder,  and  then  gently  with- 
drawing filiform  and  telescope  as  one  piece.  Theoretically,  the  passage 
of  the  wax  tip  through  the  open  eye  of  the  sheath  might  result  in  a 
scratch ;  but  I  have  never  known  this  to  happen,  and  the  advantage  of 
making  the  examination  in  this  way  is  that  the  wax-tipped  bougie  may 
then  be  withdrawn  from  the  telescope,  and  set  aside  for  confirmatory 
examination.  The  telescope  is  then  reintroduced  armed  with  ureter 
catheters  whereby  both  ureters  may  be  catheterized,  and  specimens 
obtained  for  estimating  the  infection  and  the  impairment  of  function 
of  each  kidney. 

Hinman  has  further  perfected  this  method  by  using  a  wax-tipped 
catheter  in  an  operating  cystoscope,  protecting  it  with  a  rublier  tube 
with  which  it  is  introduced  into  the  sheath  of  the  instrument.  I  have 
not  employed  this  technic. 

It  has  been  still  further  suggested  that  several  bulbs  be  put  upon 
the  catheter  so  that  if  this  is  introduced  a  known  distance  into  the  ureter 
the  scratches  on  the  several  bulbs  will  indicate  the  position  of  the  stone 
in  the  ureter.'  This  oechnic  implies  a  precision  of  manipulation  which 
is  possessed  by  but  few  operators  and  a  fixity  in  the  ureter  not  charac- 
teristic of  all  stones. 


396  RENAL  AND  URETERAL  CALCULUS 

Geraghtj  and  Hinman  ^  failed  to  show  the  stone  by  radiography  in 
15  out  of  67  cases  of  ureter  calculus:  7  of  these  were  subsequently 
passed,  6  others  were  diagnosed  by  the  wax-tipped  catheter,  and  2  by 
operation. 

But  even  the  wax-tipped  catheter  is  not  infallible.  I  have  not  used 
it  often  enough  to  show  any  reliable  statistics,  but  I  have  several  times 
failed  to  identify  the  presence  of  small  ureteral  calculi  by  its  use. 

Pyelography. — When  simple  radiogTaphy  fails,  the  wax-tipped 
catheter  affords  the  most  accurate  means  of  diagnosis  of  those  small  cal- 
culi that  are  simply  in  transit  through  the  ureter,  or  have  only  recently 
been  obstructed  therein.  Larger  stones,  and  stones  that  have  remained 
long  enough  in  the  ureter  to  cause  dilatation  of  this  duct,  are  best 
diagnosed  by  means  of  pyelography.  Plate  IV  illustrates  how  ac- 
curately the  injected  fluid  outlines  the  dilatation  of  the  ureter  about  the 
stone  itself,  and  the  dilatation  of  the  duct  above  it.  Such  a  picture, 
confirmed  by  appropriate  evidences  of  impaired  renal  function  and 
infection,  constitutes  a  definite  diagnosis. 

A  satisfactory  injection  may  often  be  made  even  when  the  catheter 
will  scarcely  enter  the  lower  end  of  the  ureter,  for  if  this  grasps  the 
ureter  catheter  tightly  the  fluid  slowly  injected  will  mount  the  channel 
in  sufficient  density  to  give  a  good  picture. 

Ureter  Catheter  Diagnosis. — The  wax-tipped  catheter  and  pyelog- 
raphy are  rather  accessories  to  the  x-ray  diagnosis  of  renal  and  ureteral 
stone.  Moreover  the  cystoscope  may  reveal  bulging  or  inflammation 
of  the  intramural  portion  of  the  ureter  due  to  the  presence  of  stone. 
A  stone  may  be  seen  projecting  from  the  ureter  mouth,  or  it  may  be 
recognized  by  impact  upon  the  ureter  catheter  introduced  into  that 
channel  (though  it  is  usually  quite  impossible  to  distinguish  the  ob- 
struction due  to  stone  from  that  due  to  any  other  cause). 

The  visible  ureter  catheter  is  also  essential  to  the  diagnosis  of 
stone  in  the  lower  ureter,  and  described  in  Chapter  IX. 

The  primary  function  of  the  ureter  catheter  is  the  study  of  renal  / 
physiology  rather  than  the  study  of  renal  pathological  anatomy.  The 
diagnosis  of  renal  and  ureteral  stone  is  not  complete  without  catheteriza- 
tion of  the  ureters  for  the  purpose  of  studying  the  renal  function  and 
the  presence  or  absence  of  inflammation  of  the  kidneys.  Though  the 
results  obtained  vary  beyond  the  scope  of  any  tabulation  we  may 
attempt  to  classify  them  loosely  as  follows: 

The  impairment  of  kidney  function  by  even  a  series  of  renal  colics 
may  be  singularly  slight.  For  a  few  hours  after  the  colic  the  phenol- 
sulphonephthalein  output  may  be  extremely  low,  but  it  may  then  return 
to  normal.  The  urine  obtained  by  ureter  catheter  after  a  renal  colic 
is  likely  to  show  red  blood  cells,  and  may  show  pus.     But  the  presence 

^Surg.,  Gyn.  4-  Obstet.,  May,  1915,  xx,  515. 


DIFFERENTIAL  DIAGNOSIS  397 

of  red  blood  cells  must  be  disregarded  on  account  of  the  possibility 
of  their  having  been  due  to  a  scratch  from  the  catheter. 

On  the  other  hand,  chronic  pyelonephritis  due  to  stone  is  usually 
bilateral  even  though  the  stone  be  unilateral,  and  the  opposite  kidney 
usually  shows  considerable  impairment  of  its  function. 

Exploratory  Operation. — Calculous  anuria,  and  rupture  of  the  ure- 
ter are  the  only  two  conditions  that  so  immediately  require  operation 
for  simple  drainage  as  to  warrant  the  neglect  of  a  preceding  ureter 
catheterization.  But  if  the  facilities  are  at  hand,  a  preliminary  ureter 
catheterization  is  desirable  even  in  these  conditions.  (Other  condi- 
tions due  to  stone  may  all  be  diagnosed  by  the  methods  described.) 

The  exploration  under  such  conditions  should  consist  in  drainage 
of  one  or  both  kidney  pelves  to  save  the  patient's  life.  Search  for  the 
stones  should  be  deferred  to  a  calmer  moment. 


DIFFERENTIAL  DIAGNOSIS 

So  varied  is  the  symptomatology  of  renal  calculus  that  it  is  often 
overlooked  entirely,  and  more  often  mistaken  for  some  other  malady. 

It  must  be  distinguished  from  other  causes  of  abdominal  pain  and 
colic  both  within  (passage  of  crystals,  pyonephrosis,  tuberculosis,  hydro- 
nephrosis) and  without  the  urinary  tract  (appendicitis,  cholecystitis, 
vesiculitis,  pancreatitis,  oophoritis).  It  is  furthermore  to  be  distin- 
guished from  such  causes  of  hematuria  as  nephritis,  renal  or  vesical 
neoplasm,  or  tuberculosis,  etc.,  and  such  causes  of  anuria  as  hysteria. 

It  were  a  waste  of  words  to  assemble  in  contrast  here  the  various 
signs  that  distinguish  these  diseases. 

Let  us  dwell  only  upon  three  important  points,  viz. : 

1.  The  possibility  of  "renal"  colic  without  stone. 

2.  Differentiation  between  stone  and  appendicitis. 

3.  Differentiation  of  calculous  anuria. 

Pseudorenal  Colic — I  have  reported  several  cases  ^  in  which  the 
passage  of  crystals  or  blood  clots  from  the  kidney,  intestinal  colic,  and 
vesiculitis  precisely  resembled  renal  colic  in  their  subjective  symptoms. 
Biliary  and  appendicular  colic  and  Dietl's  crises  also  simulate  true 
renal  colic.  Many  physicians  cherish  the  delusion  that  such  pseudo- 
renal  colics  are  not  as  intense  as  the  colics  due  to  stone  and  do  not, 
for  example,  require  morphin.  But  in  intensity  there  seems  little  choice 
between  them.  The  diag-nosis  must  be  made  by  the  x-ray  and  ureter 
catheter  and  with  little  regard  to  the  intensity  of  the  paroxysm. 

Stone  and  Appendicitis — Ureteral  stone,  arrested  at  or  near  the 
pelvic  brim,  is  only  one  of  many  conditions  which  is  frequently  mis- 

*  Trans.  Am.  Assn.  Gen.-JJrin.  Surg.,  1906,  vol.  i. 


398  RENAL  AND  URETERAL  CALCULUS 

taken  for  appendicitis.  Conversely,  the  inflamed  appendix  may  not  only 
excite  hematuria  ^  from  toxic  nephritis  (nephrite  toxique  appeudiculaire 
of  Dieulafoy),  bacterial  nephritis  or  involvement  of  the  ureter  in  the 
inflammatory  process ;  it  may  also  excite  any  of  the  subjective  symp- 
toms ^  (such  as  renal  colic,  frequent  and  painful  urination  and  lumbar 
tenderness)  that  pertain  to  these  conditions. 

Doubtful  cases  must  be  submitted  to  every  technical  examination, 
i.  e.,  functional  tests,  radiography,  wax-tipped  catheter,  and  pyelog- 
raphy, before  being  explored  surgically. 

Diagnosis  of  Calculous  Anuria. — Anuria  may  be  due  to  many 
causes.  The  terminal  anuria  of  nephritis  (whether  calculous  or  not) 
and  the  acute  anuria  of  toxic  nephritis  are  accompanied  by  other  grave 
symptoms  that  distinguish  them  plainly  from  calculous  anuria.  But 
hysterical  anuria  may  be  quite  confusing.  Thus  Gordon  ^  has  reported 
a  case  of  hysterical  anuria  lasting  two  days  and  cured  by  suggestion, 
while  Grenier  *  saw  a  hysterical  young  woman  through  five  attacks  of 
anuria  lasting  respectively  two,  four,  six,  eight,  and  fifteen  days. 
Papin  ^  cites  five  cases  to  show  that  anuria  may  be  the  initial  symptom 
of  cancer  of  the  rectum.    I  have  seen  anuria  as  a  result  of  nephroptosis. 


TREATMENT 

Prophylactic  Treatment. — See  p.  379. 

Palliative  and  Symptomatic  Treatment. — The  patient  suffering  from 
renal  calculus  may  require  palliative  treatment  under  the  following 
conditions : 

1.  During  an  attack  of  renal  colic. 

2.  During  a  period  of  quiescence. 

Teeatment  of  Renal  Come. — Renal  colic  calls  for  the  relief  of 
pain,  not  only  as  a  means  of  alleviating  suffering,  but  also  for  the 
purpose  of  relaxing  the  vireteral  spasm  about  the  stone,  and  expediting 
its  passage  into  the  bladder.  Morphin  should  be  given  subcutaneously 
with  a  generous  hand,  and  the  patient  put  to  bed  and  swathed  in  hot 
blankets  if  the  attack  is  severe.  Sometimes  a  colon  irrigation  seems  to 
help-  to  dislodge  the  stone. 

If  the  attack  continues  the  ureters  should  be  catheterized,  and 
glycerin  injected  in  the  hope  of  relaxing  the  ureteral  spasm. 

Severe  pain  may  require  general  anesthesia  for  its  relief. 

*  Seelig,  Ann.  Surg.,  1908,  xlviii,  388. 

^De  Meo,  Guyon's  Annates,  1910,  xxviii,  2115. 
^Med.  Rec,  1900,  Iviii,  289. 

*  Jour,  de  med.  de  Bordeaux,  1902,  xxxiv. 
^Bev.  de  Gyn.,  1908,  xii. 


TREATMENT  399 

At  the  earliest  possible  opportunity  an  x-ray  should  be  obtained, 
since  the  need  of  operation  may  suddenly  arise.  The  persistence  of  a 
swollen  and  tender  kidney  after  the  colic  has  ceased  is  suggestive  evi- 
dence of  the  fact  that  the  ureter  remains  occluded.  Therefore,  if  the 
kidney  remains  tender  the  ureters  should  be  catheterized  to  determine 
whether  the  ureter  is  occluded.  If  so,  the  case  should  be  treated  as 
one  of  anuria,  and  instant  operation  urged. 

But  if  the  colic  passes  without  leaving  any  tenderness  or  swelling 
in  the  kidney  or  any  evidence  of  acute  renal  infection,  the  patient 
should  nevertheless  submit  to  thorough  x-ray  examination  and  cystos- 
copy with  the  use  of  the  wax-tipped  catheter  and  of  injection  for  the 
purpose  of  diagnosing  the  situation  of  the  stone  and  hastening  its  pas- 
sage into  the  bladder. 

Teeatment  of  Calculous  Anuria. — As  soon  as  calculous  anuria 
is  diagnosed,  i.  e.,  as  soon  as  it  is  known  that  there  is  anuria,  and 
that  the  anuria  is  due  to  calculus,  operation  should  be  performed.  Delay 
is  inexcusable  except  for  the  purpose  of  making'  the  diagnosis  more 
accurate.  If  the  patient  is  seen  in  the  first  day  or  two  of  the  anuria, 
he  should  be  x-rayed  for  the  purpose  of  locating  the  stone,  and  an 
attempt  should  be  made  by  the  passage  of  ureter  catheters  and  the 
injection  of  glycerin  to  relieve  the  anuria.  No  more  than  24  hours 
should  be  spent  in  this  effort,  and  if  the  anuria  has  lasted  for  more 
than  three  days,  not  even  this  waste  of  time  is  permissible — operation 
must  be  performed  at  once. 

Watson  and  Cunningham  collected  205  cases  of  calculous  anuria,  of 
which  95  were  operated  upon  with  46  per  cent  mortality,  110  were  not 
operated  upon,  with  72  per  cent  mortality.^ 

Huck  ^  states  that  operation  before  the  fourth  day  gives  a  mortality 
of  25  per  <;ent;  before  the  fifth  day,  30  per  cent;  before  the  sixth  day, 
42  per  cent. 

No  matter  how  perfect  the  x-ray  picture,  there  must  always  remain 
some  doubt  as  to  the  condition  of  the  kidneys  or  the  existence  of 
secondary  kinks  above  a  stone  low  down  in  the  ureter.  Therefore,  it 
is  almost  a  universal  rule  that  the  x-ray  findings  should  be  neglected, 
and  pyelotomy  performed  solely  for  the  purpose  of  saving  the  patient's 
life,  and  removing  any  stones  that  may  be  found  in  the  pelvis  of  the 
kidney.  Watson  has  suggested  that  the  pyelotomy  should  always  be 
bilateral.  I  have  acted  upon  this  suggestion  two  or  three  times,  and 
have  never  had  cause  to  regret  it.  There  is  certainly  a  lesion  in  both 
kidneys — the  patient's  life  is  seriously  endangered  through  their  luck 
of  function ;  they  had  both  better  be  drained. 

No  immediate  attention  need  be  paid  to  a  stone  low  down  in  the 

*  " Genito-Urinary  Diseases,"  1908,  ii,  193. 

'Quoted  by  Walker,  " Genito-Urinary  Surgery,"  1914,  p.  282. 


400  RENAL  AND  URETERAL  CALCULUS 

ureter.  With  relief  of  pressure  by  drainage  of  the  kidney  pelvis,  this 
stone  may  pass  spontaneously  and  with  scarcely  any  pain.  I  have  twice 
known  this  to  happen  after  operation  for  calculous  anuria. 

Treatment  During  a  Period  of  Quiescence. — Patients  known  to 
possess  renal  calculi  which  are  not  causing  symptoms  fall  into  two 
classes : 

1.  Patients  who  have  not  passed  the  ureteral  calculus  that  has 
caused  a  colic. 

2.  Patients  whose  renal  calculi  have  remained  silent  in  the  pelvis 
until  they  have  attained  a  great  size  and  have  caused  grave  pyelo- 
nephritis or  pyonephrosis. 

If  a  ureteral  calculus  having  caused  a  renal  colic  remains  in  the 
ureter,  and  radiography  shows  that  its  transverse  diameter  does  not 
exceed  1  cm.  every  effort  should  be  made  to  encourage  its  passage. 
The  patient  should  drink  as  much  water  as  possible,  and  attempts 
may  be  made  at  oil  injections  through  the  ureter  catheter,  though  these 
usually  fail.  Pully  one-half  of  such  calculi  pass  spontaneously,  how- 
ever, and  one  may  properly  await  their  discharge  for  fully  six  months. 
If  a  radiograph  is  taken  from  time  to  time,  and  shows  that  the 
stone  is  moving  downward  toward  the  bladder,  this  is  an  encouraging 
symptom,  while  the  recurrence  of  colics  and  immobility  of  the  stone 
discourage  delay.  Precisely  how  long  one  should  wait  in  any  given 
case  must  be  decided  empirically.  I  once  encouraged  a  patient  to  await 
the  passage  of  his  stone,  this  being  half  way  down  his  ureter  and  causing 
him  little  impairment  of  the  renal  function.  Yet  his  next  colic  was 
followed  by  rupture  of  the  ureter.  I  performed  an  emergency  operation 
and  he  recovered  after  a  stormy  and  prolonged  convalescence. 

If  the  stone  is  2  cm.  or  more  in  width,  it  will  probably  not  pass,  and 
dangerous  complications  may  be  prevented  by  early  operation. 

RADICAL    TREATMENT 

But  if  the  patient  with  quiescent  stone  is  of  the  other  type,  with  a 
large  stone  in  a  suppurating  kidney,  while  he  may  go  for  years  without 
grave  symptoms,  he  is,  nevertheless,  in  a  state  of  unstable  equilibrium, 
carrying  about  within  him  a  septic  focus,  the  source  of  probable  in- 
fection to  the  other  kidney,  and  a  deteriorating  influence  upon  his  whole 
economy.  He  may  at  any  time  fall  a  victim  to  an  acute  renal  infec- 
tion or  to  a  general  septicemia,  and,  like  the  patient  with  a  smoldering 
appendix,  he  should  be  urged  to  operation.  The  operation  of  choice  is 
nephrectomy,  if  the  opposite  kidney  can  support  life. 

If  both  kidneys  are  full  of  calculi,  bilateral  simultaneous  nephrot- 
omy is  the  operation  of  choice.  The  kidney  with  the  better  function 
should  be  operated  upon  first. 


TREATMENT  401 

By  the  same  token  the  only  reason  for  hesitating  to  remove  a  stone 
from  a  solitary  kidney  is  the  fact  that  the  function  of  this  kidney  is  too 
impaired  to  withstand  operation. 

The  Treatment  of  Calculous  Pyelonephritis Renal  suppuration 

due  to  stone  is  only  one  degree  less  benign  in  appearance  and  less  malig- 
nant in  reality  than  anuria.  Suppuration  caused  by  calculus  cannot 
be  overcome  by  any  medical  or  hygienic  treatment.  Unless  the  stone 
can  be  passed  off  spontaneously — an  outcome  to  the  last  degree  improb- 
able in  suppurating  cases — its  growth  is  fostered  by  secondary  phos- 
phatic  deposit,  while  the  irritation  it  provokes  in  turn  feeds  the  renal 
suppuration.     The  stone  must  be  removed. 

Pyonephrosis  and  perinephritic  abscess,  whether  calculous  or  not, 
require  radical  surgery. 

Methods  of  Radical  Treatment — The  radical  treatment  of  renal  and 
ureteral  calculus  consists  of  three  operative  procedures :  nephrolithot- 
omy, nephrotomy,  and  nephrectomy.  ISTephrolithotomy  (pyelolithot- 
omy  or  ureterolithotomy)  is  incision  of  the  kidney  (pelvis  or  ureter) 
for  the  purpose  of  extracting  a  stone.  The  term  has  been  restricted  to 
operations  performed  upon  the  aseptic  kidney,  to  distinguish  them  from 
nephrotomy  performed  upon  the  suppurating  kidney.  This  distinction 
is  valuable  from  a  surgical  point  of  view.  The  term  nephrolithotomy, 
therefore,  will  be  employed  to  designate  extraction  of  a  stone  from  a 
nonsuppurating  kidney,  while  nephrotomy,  in  this  connection,  will 
imply  lithotomy  of  a  suppurating  organ. 

Indication  for  Operation. — The  general  indication  for  operation  is 
the  presence  of  a  stone  too  large  to  pass  down  the  ureter.  If  the  calculus 
is  too  large  to  pass  of  itself  it  must  be  removed  by  the  surgeon.  In  the 
preceding  paragraphs  the  modifying  circumstances  have  been  discussed 
— the  delusive  nature  of  the  calm  succeeding  a  renal  colic,  the  imperative 
necessity  for  operation  during  anuria,  the  futility  of  delay  when  the 
kidney  is  suppurating. 

The  mortality  from  nephrolithotomy,  pyelolithotomy  and  uretero- 
lithotomy does  not  run  above  2  to  4  per  cent.  Such  a  prospect,  with  its 
assurance  of  future  safety,  its  lack  of  present  danger,  and  its  unim- 
portant discomforts,  outweighs  a  single  renal  colic,  and  is  not  for  a 
moment  to  be  compared  with  the  progressive  unsafety  and  discomfort 
to  which  a  patient  subjects  himself  by  refusing  operation. 

The  advantage  of  early  operation,  before  the  kidney  becomes  in- 
fected, is  still  further  enforced  by  the  relative  mortality  of  nephro- 
lithotomy, nephrotomy,  and  nephrectomy.  Nephrolithotomy — the  re- 
moval of  a  stone  from  an  uninflamed  kidney  or  ureter — has,  as  remarked 
above,  a  mortality  of  2  to  4  per  cent.  Nephrotomy — the  incision  of  a 
septic  kidney — has  a  mortality  of  20  per  cent  to  25  per  cent,  while  tlie 
mortality  of  nephrectomy  in  like  conditions  runs  from   30   ])cr  cent 


402  RENAL  AND  URETERAL  CALCULUS 

upward.  Add  to  this  the  mortality  of  nephrotomy  for  calculous  anuria 
(50  per  cent),  and  the  conclusion  is  ohvious  that  the  patient  who  re- 
fuses surgical  relief  while  the  kidney  is  yet  uninflamed  spurns  a  com- 
paratively safe  and  sure  cure  and  subjects  himself  to  a  disease  which, 
apart  from  its  other  dangers  and  discomforts,  may  at  any  moment  bring 
him  to  a  critical  condition  of  renal  obstruction  or  suppuration,  from 
which  he  can  only  escape  by  submitting  to  an  operation  many  times  more 
dangerous  and  distressing  than  the  one  he  seeks  to  avoid.  Further- 
more the  longer  operation  is  deferred  the  greater  prospect  is  there  of 
irreparable  damage  to  the  kidney,  and  also  the  persistence  of  stricture 
or  obstruction  in  pelvis  or  ureter  calculated  to  cause  prompt  relapse 
of  stone  and  persistence  of  fistula.. 


CHAPTER    XLI 
CALCULI  AND  FOREIGN  BODIES  OF  BLADDER  AND  URETHRA 

VESICAL  CALCULUS 

Number  and  Shape — Single  calculi  are  generally  ovoidal  in  shape 
(Figs.  27  to  29;  71  to  73;  PL  I). 

Multiple  calculi  are  usually  phosphatic,  less  frequently  urates.  In 
general,  their  number  bears  an  inverse  relation  to  their  size.    When  few 


Fig.  83. — Large    Renal    Calculi.     Radiograph    by    Dr.    MacKcc.     Tlic    patient's    only 
symptom  was  an  occasional  renal  colic.     General  health  excellent.     Refuses  operation. 

in  number  they  influence  one  another's  shape  and  grow  to  be  iiiaiiy- 
sided  rather  than  rounded  (Figs.  74,  70).  ITence  when  a  atone  passed 
spontaneously  presents  one  or  more  flat  sides  or  facets,  the  presence  of 
other  stones  may  be  inferred. 

403 


404     CALCULI  AXD  FOREIGN  BODIES  OF  BLADDER  AXD  URETHRA 

Fantastic  dumbbell  and  other  shapes  are  assumed  by  encysted  cal- 
culi (Fig,  83 ),  part  of  the  stone  taking  the  shape  of  the  pocket  which 
contains  it,  while  the  remainder  protrudes  irregularly  into  the  vesical 
cavity. 

Size — Partly  on  account  of  the  infrequency  of  stone,  partly  on  ac- 
count of  the  surgeon's  omnipresence,  large  stones  are  rarely  seen  in 
this  day  and  in  this  country.  The  largest  stone  in  my  collection  weighs 
13  ounces.  Dr.  Thomas  Smith  ^  removed  a  stone  weighing  24-|  ounces, 
and  Lieutenant-Colonel  Bamker  -  one  weighing  25  ounces.  Such  large 
stones  are  always  phosphatic. 

Sex. — Xot  more  than  two  or  three  per  cent  of  bladder  stones  occur 
in  women  (if  we  except  incrusted  ulcers j.  I  have  operated  on  59  men 
and  no  women ;  my  father  on  250  men  and  3  women. 

Source. — A  few  vesical  calculi  are  formed  in  the  bladder  about 
foreigTL  bodies,  while  others  can  be  traced  by  the  history  of  a  renal 
colic  as  having  descended  the  ureter  and  been  caught  in  the  bladder. 
But  in  the  majority  of  cases  no  such  clear  history  is  obtainable.  There 
are  certain  probabilities  worthy  of  enumeration;  thus  the  following 
stones  usually  originate  in  the  kidney :  Congenital  stones,  stones  with 
a  history  of  renal  colic,  oxalate  stones.  While  the  primary  bladder 
stones,  apart  from  those  actually  formed  around  foreign  bodies,  are 
likely  to  be  composed  largely  of  yellow  urates  and  to  be  associated 
with  a  slight  retention  of  urine,  this  slight  retention  being  a  frequent 
cause  for  the  relapse  of  such  stones  when  they  are  removed.  Beck's  ^ 
assertion  that  almost  all  vesical  calculi  are  of  renal  origin  is  absolutely 
not  borne  out  by  the  facts.  Urate  calculi  are  found  at  least  ten  times 
more  often  in  the  bladder  than  in  the  kidney. 

SPONTANEOUS  FEACTUEE* 

Spontaneous  fracture  is  apparently  due  to  long-continued  dilution  of 
the  urine,  which  weakens  the  colloidal  framework  of  the  stone  suffi- 
ciently to  permit  it  to  break  into  pieces.  This  rare  phenomenon  has  been 
taken  advantage  of  by  the  purveyors  of  various  lithia  waters.  The  claim 
that  any  water  or  drug  will  even  probably  cause  spontaneous  fracture 
of  stone  is  not  supported  by  experience.  ]\Ioreover.  when  the  calculus 
does  break  it  is  not  to  be  expected  that  all  the  fragments  will  be  expelled. 
One  or  more  remain  in  the  bladder,  and  around  these  as  nuclei  new 
stones  will  form.  Almost  all  the  reported  cases  of  fracture  have  oc- 
curred in  pure  uric  acid  calculi.     I  have  seen  one  such  case. 

'^Lancet,  1886,  ii,  244. 

^Med.  Record,   1900,  Iviii,   637. 

^7oOT.  A.  M.  A.,  1908,  li,  885. 

*Cf.  Engliseh,  ArcMv  f.  l-Jin.  Chir.,  1905,  Ixxvi,  and  Kasamowski,  Folia 
Urologica,  January,  1909. 


VESICAL  CALCULUS 


405 


SYMPTOMS 

There  is  no  symptom,  no  set  of  symptoms,  absolutely  and  invariably 
pathognomonic  of  stone  in  the  bladder,  except  the  physical  signs  elicited 
by  the  surgeon's  examination.  Yet  there  is  a  certain  group  of  symp- 
toms which  is  very  suggestive  of  stone.  Chief  among  these  are  fre- 
quency of  urination, 
pain,  and  hematuria, 
occurring  by  day  and 
increased  by  exercise. 

Frequency  of  Uri- 
nation and  Pain. — 
These  are  usually  in- 
tense. The  distress 
is  usually  less  during 
the  night  while  the 
patient  lies  quietly  on 
his  back,  and  during 
the  day  so  long  as  he 
is  still.  But  every 
jolt  induces  spasm. 
When  walking  the 
patient  moves  slowly 
and  gingerly,  almost 
on  tiptoes.  Riding 
over  a  rough  road  or 
in  a  railroad  train,  or 
even  walking  down- 
stairs, is  misery.  The 
pains  are  situated 
chiefly  in  the  glans 
penis,  along  the  pen- 
dulous   urethra,    and 

in  the  perineum.  The  desire  to  urinate  is  quite  irresistible.  As  a 
result  of  some  extra  exertion  or  an  acute  infection,  the  patient,  from 
time  to  time,  has  what  is  known  as  a  fit  of  the  done.  During  this  time 
his  pains  are  greatly  intensified.  He  may  have  to  urinate  as  often  as 
every  ten  or  fifteen  minutes  day  and  night,  so  that  he  spends  his  time 
in  one  long  spasm. 

As  the  stone  grows  larger  and  the  cystitis  more  intense  these  parox- 
ysms become  more  and  more  frequent.  'Jliey  oxhanst  the  patient's 
strength,  and  during  them  he  resembles  a  woman  in  the  second  stage  of 
labor.  In  children,  prolapse  of  the  rectum  and  involuntary  defecation 
are  common  results  of  this  straining,  while  adults  complain  of  hemor- 


FiG.  84. — Silent  Vesical  Calculi. 


406  CALCULI  AND  FOREIGN  BODIES  OF  BLADDER  AND  URETHRA 

rhoids,  pass  blood  by  the  rectum,  and  during  the  paroxysms  suffer 
from  unavoidable  escape  of  intestinal  flatus  and  often  of  feces.  When 
there  is  considerable  prostatic  hypertrophy  or  the  stone  is  encysted, 
there  is  less  tendency  to  pain,  so  that  even  with  intense  cystitis  the 
paroxysms  may  be  neither  frequent  nor  severe. 

Exceptionally  the  pain  is  absent  or  nocturnal  in  the  absence  of  pros- 
tatism. Thus  my  two  most  recent  litholapaxies  were  performed  on  men, 
one  of  whom  had  never  had  any  pain,  though  horseback  riding  made 
him  bleed  (Fig.  84),  while  the  other  had  more  pain  when  lying  down 
than  when  sitting  up.  Both  had  large  acid  stones,  the  latter  weighing 
41  gm. 

Hematuria. — Hematuria,  like  the  characteristic  pain,  is  traumatic 
in  origin,  and  is,  during  the  first  stages  of  the  disease,  only  aroused  by 
some  jolt.  It  is  usually  associated  with  pain,  and  the  hemorrhage, 
though  profuse,  is  usually  short-lived.  Later  in  the  disease  the  per- 
petual straining  due  to  cystitis  may  make  the  hematuria  quite  con- 
tinuous. 

Stoppage. — Sudden  stoppage  of  the  urinary  stream  is  a  symptom 
of  stone  which  is  neither  characteristic  nor  common.  It  is  caused  by 
the  stone  rolling  into  the  vesical  orifice  and  plugging  it  like  a  ball- 
valve.  Striking  cases,  like  that  of  Sir  Henry  Thompson,  whose  patient 
could  urinate  only  while  lying  on  his  back,  are  most  uncommon.  Pros- 
tatics  with  stone  do  not  show  this  symptom,  and  it  may  be  caused  by 
prostatic  or  vesical  tumor. 

In  children  certain  special  symptoms  are  associated  with  stone,  nota- 
bly priapism  and  a  tendency  to  pull  at  the  prepuce. 

Certain  reflex  pains  in  the  back,  testicle,  etc.,  are  among  the  infre- 
quent symptoms  of  stone  in  the  bladder;  they  are  due  to  prostatic 
irritation. 

DIAGNOSIS 

In  these  cystoscopic  days  when  every  obscure  case  of  bladder  or 
renal  infection  submits  to  cystoscopy  and  radiography,  one  is  not  sur- 
prised occasionally  to  find  an  unlooked-for  bladder  stone.  Stone  is 
suspected  when  the  previously  related  symptoms  are  found. 

If  the  bladder  is  much  inflamed,  the  cystoscope  may  not  readily 
distinguish  a  stone  from  a  sloughy  tumor,  or  from  a  tumor  incrusted 
with  phosphates.  If  there  is  any  doubt  the  cystoscope  may  be  used  as 
a  searcher  to  tap  against  the  stone.  The  sensation  imparted  distin- 
guishes the  solid  stone. 

Large  stones  can  be  readily  diagnosed  by  tapping  with  almost  any 
urethral  instrument  excepting  a  soft  rubber  catheter;  even  the  woven 
catheter  will  strike  its  end  against  the  stone  and  give  the  characteristic 
impact. 


VESICAL  CALCULUS  407 

Small  stones,  on  the  other  hand,  are  very  elusive,  and  are  not  found 
readily  by  the  old-fashioned  searcher  while  the  encysted  stone  and  the 
stone  behind  the  prostate  elude  this  as  well.  For  these  reasons  the  stone 
searcher  has  quite  fallen  into  disrepute,  and  been  replaced  by  the 
cystoscope. 

The  presence  of  bladder  stone  leads  to  the  suspicion  of  renal  stone; 
this  should  be  proven  by  x-ray  and  renal  function  tests. 

PROGNOSIS 

Unless  the  stone  is  small  enough  to  be  viable  through  the  urethra, 
there  is  only  one  prognosis — it  will  certainly  remain,  and  the  symptoms 
will  inevitably  grow  more  severe  until  it  is  removed  by  operation. 

TREATMENT 

The  treatment  of  stone  in  the  bladder  is  operative.  The  choice 
of  operation  depends  in  some  measure  upon  the  patient's  condition,  in 
some  measure  upon  the  surgeon's  skill.  The  surgeon  may  choose  be- 
tween three  operations :  litholapaxy,  suprapubic  and  perineal  lithotomy. 

The  performance  of  litholapaxy  requires  a  training  and  an  oppor- 
tunity for  performing  the  operation  with  relative  frequency  which  few, 
even  among  specialists,  can  command.  Litholapaxy  is  the  operation  of 
choice  at  the  hands  of  a  skilled  operator  for  all  uncomplicated  and 
relatively  small  cases  of  stone  in  the  bladder.  Each  surgeon  must 
decide  for  himself  what  type  of  case  he  considers  suitable  for  the 
operation.  In  India,  where  bladder  stones  are  extremely  frequent 
among  young  people,  litholapaxy  is  preferred  above  all  other  opera- 
tions, even  for  large  stones.  In  this  country,  where  stones  are  rela- 
tively few,  and  usually  due  to  retention  of  urine,  many  specialists  do 
not  perform  litholapaxy  at  all.  I  prefer  the  operation  in  adults  for 
uncomplicated  stone  up  to  about  a  diameter  of  4  cm. 

Suprapubic  lithotomy  is  the  operation  of  choice  for  large  stones, 
for  children,  for  stones  the  result  of  prostatism,  or  other  pathological 
conditions  about  the  bladder  requiring  operation.  Its  mortality  in 
slightly  gTcater,  its  convalescence  slightly  longer  than  litholapaxy, 
I  have  never  lost  a  patient  after  litholapaxy,  though  I  have  several 
times  had  to  repeat  the  operation  on  account  of  fragments  left  behind 
at  the  first  crushing. 

Perineal  lithotomy  is  the  operation  of  choice  when  some  condition 
in  the  urethra,  such  as  stricture,  requires  a  perineal  section. 

The  mortality  of  operations  upon  large  bladder  stones  is  extremely 
high,  because  these  cases  invariably  have  a  gravely  impaired  renal 
function  through  chronic  renal  infection.     Preliminary  examination  by 


408     CALCULI  AND  FOREIGN  BODIES  OF  BLADDER  AND  URETHRA 

phenolsulphoiiephtlialein  discloses  this  condition  and  indicates  the  neces- 
sity for  great  care  in  the  selection  of  an  anesthetic.  Generally  speaking, 
such  cases  should  be  operated  upon  by  suprapubic  lithotomy  under  a 
local  anesthetic. 


FOREIGN  BODIES  OF  THE  BLADDER 


Foreign  bodies  may  enter  the  bladder  down  the  ureter,  through  the 
wall  of  the  bladder,  or  up  the  urethra. 

Ureteral. — Crystals,  stones,  blood  clots,  shreds  of  tissue,  descend  the 
ureter  and  may  be  caught  in  the  bladder. 

Parietal.^ — Apart  from  the  substances 
which  may  be  introduced  through  wounds, 
there  are  two  types  of  parietal  foreign 
bodies.  One  consists  of  the  gauze  sponges, 
etc.,  that  may  be  left  in  the  bladder  at  the 
time  of  operation,  and  the  silk  sutures  with 
which  the  bladder  may  be  tied  and  which 
work  their  way  into  that  organ.  The  sec- 
ond class  of  parietal  foreign  bodies  reach 
the  bladder  through  the  bursting  and 
emptying  of  the  abscess  containing  them 
into  the  bladder,  of  such  objects  as  pins 
may,  of  their  own  impetus,  migrate  into 
the  bladder  without  suppuration. 

Urethral. — Foreign  bodies  are  intro- 
duced into  the  bladder  through  the  urethra 
by  the  insane  and  the  peryert.  This  prac- 
tice is  much  more  common  in  certain 
European  countries  than  in  the  United 
States.  These  foreign  bodies  are  much 
more  likely  to  slip  through  the  short 
urethra  of  a  woman  than  that  of  the  man. 
Consequently,  they  are  much  more  com- 
monly found  in  women's  bladders.  The 
substances  usually  employed  are  chewing 
gum,  hair  pins,  and  hat  pins. 

In  this  manner  eyery  substance  that 
the  urethra  will  admit  has  at  one  time  or  another  been  introduced  into 
it,  and  been  found  in  the  bladder  subsequently.  It  were  a  waste  of 
time,  therefore,  to  attempt  any  specific  enumeration.  The  curious  may 
refer  to  the  exhaustiye  monograph  of  Englisch.^ 
^Deutsch.  Zeitschr.  f.  Chir.,  1906,  Ixxxix. 


Fig.  85. — Stone  on  TVig. 
URAL  Size. 


Nat- 


FOREIGN  BODIES  OF  THE  BLADDER 


409 


A  generation  ago  it  was  not  uncommon  for  catheters  to  break  off 
inside  the  bladder ;  improvement  in  their  manufacture  makes  this  acci- 
dent most  uncommon  nowadays,  but  our  intravesical  operative  instru- 
ments sometimes  break  and  are  thus  lost. 

Blood  clots  and  bits  of  sloughing  tissue  left  in  the  bladder  after 
operation    form    the 
nuclei    of    postprosta- 
tectomy  calculi. 

Results — The  for- 
eign body  may  remain 
silent  in  the  bladder 
for  a  considerable 
length  of  time,  espe- 
cially if  it  be  small, 
rounded  or  soft.  But 
sooner  or  later  staphy- 
lococcus or  streptococ- 
cus infection  occurs, 
phosphatic  incrusta- 
tion ensues,  and  a 
phosphatic  stone  de- 
velops around  the  for-  Fig.  86.— Stones  Formed  on  Hairs  of  a  Dermoid  Cyst 
eiffn  body  as  a  nucleus  Ruptured  into  the  Bladder.     Natural  Size. 

(Fig.  85).    The  symp- 
toms thereafter  are  those  of  stone.    Such  stones  are  usually  best  attacked 
by  cystotomy,  though  gum,  pins,  etc.,  may  be  extracted  by  means  of  the 
cystoscopic  forceps. 

PILIMICTION 

The  one  special  type  of  vesical  foreign  body  which  has  received 
distinguished  mention  in  the  past  is  best  known  under  the  title  of 
"pilimiction" — the  urination  of  hair.  My  father  had  one  such  case,  an 
insane  patient,  who  introduced  the  hair  into  his  bladder  through  the 
urethra ;  but  it  may  be  set  down  as  an  almost  universal  rule,  if  the 
patient  urinates  hair,  or  stone  formed  upon  hair  (Fig.  86),  that  this 
comes  from  a  dermoid  cyst  which  has  ruptured  into  the  bladder. 
Heller^  has  collected  57  cases  of  this  condition.  I  have  seen  one  case 
which  was  readily  identified  by  cystoscopy.  The  treatment  required  is 
excision  of  the  dermoid  cyst. 

^Zeitschr.  f.   Urol,  1913,  ii,  1, 


410     CALCULI  AND  FOREIGN  BODIES  OF  BLADDER  AND  URETHRA 


URETHRAL  FOREIGN  BODIES 

roreign  bodies  may  enter  the  urethra  at  either  extremity  or  may 
develop  in  and  about  the  canal. 


From  without 


Fragments  of  surgical  instruments.     Substances  introduced  by  the 

intoxicated,   insane,  or   sexually  perverted. 
Renal  or  vvesical  calculi,  or  any  substance  which  might  form  a  nu- 
cleus for  such  calculi. 
Originating  in  or  )  ^         _  \  Formed  about  a  foreign  body,  or  in  an  ulcerated  spot, 


From  within 

riginating 
about  the  canal,   f  "j      pocket,  or  fistula.     Prostatic  calculus, 

Varieties. — The  most  varied  substances  are  found  in  the  urethra, 
introduced  by  the  patient  under  the  influence  of  that  perverted  and 
depraved  sexual  instinct  which  affects  the  male  of  all  ages  who  gives 
up  his  mind  to  impure  thoughts  and  whose  sexual  necessities  are  not 
gratified. 

Seeds,  stones,  beads,  beans,  peas,  nails,  pins,  needles,  hairpins,  slate- 
pencils,  portions  of  glass,  wax,  cork,  and  a  host  of  other  substances  are 
thus  introduced  into  the  meatus  and,  slipping  beyond  the  reach  of  the 
fingers,  are  not  infrequently  swallowed  by  the  urethra.  Broken  cath- 
eters and  bougies,  especially  in  cases  of  stricture,  and  instruments  left 
a  demeure,  if  not  well  fastened,  may  slip  past  the  meatus  and  travel 
toward  the  bladder.  Their  tendency  is  to  slip  persistently  onward,  not 
because  of  any  urethral  suction  or  peristalsis,  but  merely  because  they 
are  introduced  blunt  end  first,  and  consequently,  unless  quite  round, 
the  outer  end  is  likely  to  be  the  sharper.  Therefore  every  erection  or 
effort  at  extraction,  if  it  move  the  foreign  body  at  all,  pushes  it  inward. 
Hounded  bodies,  such  as  beans  or  pebbles,  lie  in  the  natural  pouches 
of  the  canal  (fossa  navicularis,  bulbous  urethra)  or  become  arrested 
by  stricture. 

If  foreign  bodies  are  not  removed,  one  of  three  consequences  follows : 
1.  They  travel  on  into  the  bladder  and  form  a  nucleus  for  stone  there ; 
or,  2.  Stone  forms  around  them  in  the  urethra ;  or,  3.  They  cause  ure- 
thritis, retention  of  urine,  and  finally  either  become  encysted  or  ulcerate 
their  way  out,  producing  fistula  and  stricture. 

Treatment — If  the  body  be  long  and  soft  (catheter,  piece  of  wood), 
it  may  be  transfixed  with  a  stout  needle  through  the  floor  of  the  urethra 
and  the  canal  pushed  back  over  it,  like  a  glove  over  a  finger,  as  far  as 
possible,  when  it  may  be  transfixed  again,  and  so  urged  forward  until 
it  reaches  the  meatus.  In  manipulating  with  forceps,  if  the  finger  on 
the  outside  can  detect  and  get  behind  the  foreign  body,  nothing  should 
divert  the  surgeon  from  keeping  up  pressure  at  that  point  in  order  to 


URETHRAL  CALCULUS  411 

prevent  his  instrument  from  pushing  the  offending  substance  still 
deeper  into  the  canal. 

If  the  foreign  body  lies  behind  a  stricture,  the  latter  must  be  cut 
or  rapidly  dilated  to  allow  the  passage  of  an  instrument  suitable  for 
extraction. 

Pins  and  needles  may  be  extracted  through  the  floor  of  the  canal  if 
their  blunt  ends  can  be  steadied.  To  remove  a  pin  its  point  is  pushed 
through  the  urethral  floor  and  its  shaft  drawn  out  until  the  head  can  be 
turned  so  as  to  extrude  through  the  meatus. 

My  father  once  extracted  a  pin  with  Thompson's  divulsor,  and  Dief- 
fenbach  removed  one  from  the  membranous  urethra  by  pushing  it  with 
his  finger  in  the  rectum  until  the  point  protruded  through  the  perineum, 
and  then  forcibly  extracting  it. 

All  other  manipulations  failing,  perineal  section  will  reveal  the  posi- 
tion of  the  object  and  permit  extraction.  The  penile  or  the  scrotal  ure- 
thra should  not  be  incised  for  fear  of  fistula  in  the  one  case,  infiltration 
in  the  other. 

URETHRAL  CALCULUS 

Urethral  calculus  is  usually  a  urinary  calculus  arrested  in  the  ure- 
thra. Less  often  it  forms  in  situ — e.  g.,  about  a  foreign  body  or  behind 
a  stricture.     Prostatic  calculi  are  mentioned  below. 

Englisch  ^  has  collected  113  cases  of  calculi  in  the  prostatic  urethra, 
149  in  the  membranous  canal,  68  in  the  bulb,  103  in  the  penile  and 
scrotal  regions,  and  41  in  the  fossa  navicularis. 

The  calculi  are  elongated  in  shape,  faceted  if  numerous,  and  if 
neglected  gTOw  to  considerable  size  and  form  pouches  in  which  they  lie. 

They  may  grow  to  enormous  size.  Thus  Britneff  ^  has  collected 
from  Russian  publications  records  of  urethral  calculi  weighing,  respec- 
tively, 427  and  420  and  402  gm.  Babes  ^  records  the  spontaneous 
expulsion  through  the  female  urethra  of  a  stone,  3x4.5x6.5  cm.,  weigh- 
ing 76  gm.     She  was  left  with  incontinence  of  urine. 

Symptoms — If  the  calculus  comes  from  the  bladder  the  onset  of 
symptoms  is  sudden.  As  it  enters  the  urethra  during  urination  the 
flow  stops  suddenly,  while  a  sharp  pain  is  felt.  A  second  efi^ort  may 
extrude  it  from  the  canal  or  only  impact  it  more  firmly,  or  it  may  fall 
back  into  the  bladder  and  remain  a  vesical  calculus.  Once  impacted, 
it  may  cause  complete  retention,  or,  more  commonly,  dysuria. 

If,  on  the  other  hand,  the  stone  forms  in  situ,  the  onset  of  symptoms 

^ArcMv  f.  Min.  Chir.,  1904,  Ixxii,  487;  Centralbl.  f.  Earn.  u.  Sex.  Org.,  1904, 
XV,  18,  81,  135: 

'Bev.  Clin.  d'TJrol.,  Sept.,  1912. 
^lUd.,  March,  1913. 


412     CALCULI  AND  FOREIGN  BODIES  OF  BLADDER  AND  URETHRA 

is  insidious.  First,  there  is  slight  gleet  and  some  difficulty  in  urination. 
The  gleet  becomes  slowly  worse,  and  finally  periurethritis  occurs,  which 
goes  on  to  extensive  suppuration  and  fistulization. 

Periurethral  calculi  may  remain  latent  for  a  long  time,  until  they 
obtrude  upon  the  lumen  of  the  urethra  or  excite  suppuration  in  the 
pocket  within  which  they  lie. 

Diagnosis — A  sharp  attack  of  urethral  colic  is  unmistakable,  but 
the  less  acute  conditions  just  described  simulate  stricture  of  the  urethra; 
indeed,  stricture  and  stone  often  co-exist.  The  mistake  is  not  a  vital 
one,  however,  for  any  attempt  at  dilatation  will  evoke  a  grating  sound 
characteristic  of  stone,  and  the  calculus  may  be  felt  between  the  instru- 
ment and  the  finger  externally. 

Treatment — In  acute  cases  an  attempt  may  be  made  to  push  the 
stone  back  into  the  bladder  if  it  has  not  passed  the  membranous  urethra ; 
or,  if  it  has  passed,  the  anterior  urethra  may  be  distended  with  olive  oil 
and  the  stone  worked  forward  to  the  meatus,  whence  it  may  be  extracted 
by  crushing  or  by  meatotomy.  These  failing,  the  meatus  mtiy  be  pinched 
and  the  patient  encouraged  to  urinate;  when  the  canal  is  fully  dis- 
tended the  meatus  is  released  and  the  stone  expelled  by  the  gush  of  urine. 
The  urethral  lithotrite  is  a  dangerous  instrument  and  of  doubtful 
utility.  The  scoops  and  forceps  of  Collin  and  Leroy  d'Etiolle,  though 
ingenious,  are  never  at  hand  at  the  right  moment.  When  these  methods 
fail  external  urethrotomy  succeeds. 

Periurethral  calculus  calls  for  external  urethrotomy  to  remove  the 
stone,  to  excise  the  pocket  in  which  it  lies,  and  to  divide  the  stricture. 

Infih nation,  abscess,  and  fistula  are  considered  in  Chapter  XXVII. 


PROSTATIC  CALCULUS 

Urinary  calculi  may  lodge  in  the  prostatic  urethra  or  phosphatic 
incrustations  may  form  on  gTanulations  in  the  canal  or  in  a  fistula 
leading  from  it.     These  are  urethral  rather  than  prostatic  calculi. 

True  prostatic  calculus  is  a  concretion  formed  of  phosphatic  salts 
and  epithelial  detritus  in  the  acini  of  the  gland.  Such  calculi  are  not 
uncommon  in  men  past  middle  life;  they  form  in  the  deeper  portion 
of  the  glandular  substance  of  the  lateral  lobes,  in  the  line  of  cleavage 
between  that  part  of  the  lobe  which  is  enlarged  in  prostatism  and  the 
so-called  capsule. 

Prostatic  calculi  are  usually  multiple,  and  do  not  exceed  the  size 
of  a  millet  seed.  They  always  contain  lime  salts  and  show  extremely 
well  by  x-ray  throwing  a  characteristic  mottled  shadow  of  a  generally 
rounded  outline  which  delimits  the  position  of  the  prostate  (PI.  III). 
Exceptionally,  the  calculi  attain  a  much  larger  size;  I  have  knovra 


PREPUTIAL  CALCULUS  413 

them  to  attain  a  diameter  of  3  or  4  cm.  Under  these  circumstances, 
the  calculi  are  single  or  not  more  than  three  or  four  in  number. 

The  common  millet  seed  calculi  are  usually  of  no  importance.  Ex- 
ceptionally they  excite  suppuration  in  the  gland  which  may  result  in 
sclerotic  prostatitis  and  contraction  of  the  bladder  neck  (I  have  seed 
two  such  cases).  I  have  seen  two  cases  of  severe  suppuration  in  the 
testicle  due  to  a  primary  focus  of  infection  about  a  prostatic  calculus. 

On  the  other  hand,  the  larger  calculi  cause  a  slight  degree  of 
prostatic  obstruction  (I  have  never  known  this  to  assume  any  impor- 
tance), producing  mild  bladder  irritability  with  small  quantities  of 
pus  in  the  urine.  These  cases  often  elude  diagnosis  because  one  does 
not  think  of  the  possibility  of  prostatic  calculus.  The  first  case  of  the 
kind  I  ever  saw  had  had  a  kidney  removed  for  tuberculosis  and  was 
being  treated  by  lavage  of  the  renal  pelvis.  The  prostate  in  such  cases 
may  be  only  slightly  enlarged,  and  this  enlargement  may  then  be  put 
down  as  an  ordinary  hypertrophy.  Careful  palpation,  however,  is 
likely  to  reveal  the  irregular  outline  of  the  stone  or  of  the  scar  tissue 
surrounding  it.  Indeed  when  the  stones  grow  very  large  they  produce 
precisely  the  effect  of  carcinoma  of  the  prostate  to  the  examining  rectal 
finger.  Indeed  so  precise  is  the  simulation  of  carcinoma,  both  in  the 
clinical  picture  and  the  enlargement  as  felt  by  rectum,  that  the  only 
way  to  avoid  mistakes  is  to  x-ray  every  case  of  supposed  carcinoma  of 
the  prostate  in  which  the  presence  of  carcinoma  is  not  absolutely  proven 
by  palpable  thickening  in  the  middle  line  or  by  evidences  of  growth 
beyond  the  limits  of  the  prostate  gland. 

The  prognosis  of  prostatic  calculus  is  absolutely  good.  'Although 
the  stones  do  not  usually  attain  any  gTcat  size  until  the  patient  is  quite 
aged,  I  have  never  known  such  cases  to  do  any  more  harm  than  to  cause 
pain  which  is  usually  quite  bearable,  epididymal  or  prostatic  suppura- 
tion which  may  require  operation,  and  contracture  of  the  bladder  neck 
which  may  cause  retention  in  a  relatively  young  man. 

The  treatment  is  operative.  The  stone  should  be  removed  by 
suprapubic  prostatectomy.  I  have  operated  both  above  and  by  the 
perineal  route,  and  can  most  highly  commend  the  suprapubic  method 
of  approach. 

PREPUTIAL  CALCULUS 

These  resemble  urethral  calculi  in  that  they  may  descend  from  above 
or  be  formed  in  situ,  and  have  been  exhaustively  studied  by  Englisch.* 
They  are  extremely  rare. 

*  Wien.  med:  Presse,  1903,  No.  47-49. 


CHAPTEK    XLII 
GENITO-URIXARY  TUBERCULOSIS 

TuBEKcuLOsis  Can  never  be  amputated.  Its  lesions  are  indeed 
usually  localized,  and  these  lesions  are  subject  to  cure.  But  the  disease 
itself  is  not  curable  in  the  sense  that  we  can  guarantee  the  patient 
against  a  relapse.  Tuberculosis  of  the  urinary  and  genital  tract  is 
spoken  of  very  often  as  though  it  were  a  thing  apart.  This  it  is  in 
the  clinical  sense.  Its  activity  is  not  usually  coterminus  with  tuber- 
culous  processes  elsewhere  in  the  body,  yet  it  is  only  one  of  the  mani- 
festations  of  tuberculosis,  and  a  relatively  rare  one.  But,  although 
urinary  and  genital  tuberculosis  stands  clinically  alone  in  the  majority 
of  instances,  there  is  practically  always  accompanying  or  antecedent  pul- 
monary tuberculosis.  This  is  often  inactive,  and  only  to  be  revealed 
during  life  by  the  x-ray.  Kocher  records  451  autopsies  on  cases  of 
tuberculosis  of  the  urinary  and  genital  organs,  80  per  cent  of  which 
showed  pulmonary  lesions  active  or  inactive.  Waldschmidt  ^  found 
89  per  cent. 

The  association  of  urinary  and  genital  tuberculosis  is  not  very  close 
in  the  female,  but  fully  one-third  of  the  men  with  tuberculosis  of  the 
epididymis  have  tuberculosis  of  the  kidney  as  well.^  G.  Walker  ^  quotes 
Saxtorph's  record  of  10,016  autopsies  with  547  cases  of  tuberculosis 
of  the  genital  and  urinary  organs.  The  kidneys  showed  miliary  lesions 
342  times,  the  bladder  4  times.  There  were  205  cases  of  chronic 
tuberculosis.  Walker  further  collected  279  cases  of  genito-urinary 
tuberculosis,  in  184  of  which  the  kidney  was  the  first  organ  attacked, 
in  80  the  epididymis,  in  6  the  prostate,  in  6  the  fallopian  tubes,  in  2 
the  seminal  vesicles,  and  in  1  the  uterus. 

Clinically  the  disease  begins  as  a  general  miliary  tuberculosis 
(which  interests  us  not)  or  else  it  begins  definitely  in  one  of  the  organs 
involved.  In  the  urinary  tract  tuberculosis  almost  always  begins  in 
the  kidney  though  exceptionally  it  may  begin  in  the  prostate.  It  never 
begins  in  the  bladder. 

In  the  genital  tract  it  usually  seems  to  begin  in  the  epididymes 
though  the  site  of  the  first  invasion  in  the  genital  tract  is  not  definitely 
known.     I  happen  to  have  seen  a  number  of  cases  of  tuberculosis  of 

^  Berl.  Tclin.  Wochenschr.,  Sept.,  1912.  *  Annals  of  Surgery,  June,  1907. 

Ubid.,  February,  1907,  p.  249, 

414 


GENITO-URINARY  TUBERCULOSIS  415 

the  prostate  without  tuberculosis  of  the  epididymis,  and  among  the 
many  cases  of  tuberculosis  of  the  epididymis  that  I  have  studied  none 
showed  an  absolutely  normal  prostate.  For  these,  and  for  other  rea- 
sons it  is  my  impression  that  genital  tuberculosis  does  not  begin  in  the 
epididymis.  Barney  has  argued  both  sides  of  this  question.^  He 
pins  his  faith  on  the  biological  fact  that  the  epididymis  is  allied  in 
origin  to  the  kidney,  and  may  therefore  be  considered  an  excretory 
organ,  wherefore  it  may  perfectly  well  be  infected  from  the  circulation 
by  tubercle  bacilli.  But  Blandini  and  T.  Walker  -  have  independently 
shown  that  a  tuberculous  epididymis  may  be  experimentally  produced 
by  inoculating  the  urethra  and  bruising  one  of  the  testicles. 

The  source  of  origin  of  genital  tuberculosis  remains  obscure  becausej 
when  cases  are  seen  clinically,  all  of  the  genital  organs  are  likely  to  jbej 
involved  on  one  side,  epididymis,  vesicle  and  prostate. 

When  then  is  the  source  of  infection^  the  blood  stream,  the  lym- 
phatics or  coitus  ?  Bulkley  ^  favors  the  latter  theory,  and  has  collected 
the  evidence  in  its  behalf.  George  Walker,  however,  says  ''it  is  pos- 
sible that  either  the  male  or  the  female  may  become  infected  during 
coitus,  but  such  an  occurrence  is  extremely  rare  and  the  few  instances 
which  have  been  reported  are  open  to  doubt."  A  few  voices  are  raised 
in  favor  of  lymphatic  origin  of  the  infection,  especially  for  a  direct 
lymphatic  invasion  of  the  kidney  from  a  tuberculosis  of  the  base  of 
the  lung.  But  the  majority  speak  in  favor  of  an  infection  from  the 
blood  stream. 

It  has  been  believed  that  gonorrhea  was  a  frequent  cause  of  tuber- 
culosis of  the  urinary  and  genital  tract.  Kummell,*  for  instance,  sup- 
ports this  view.  But  the  experience  of  most  observers  leads  to  the 
conclusion  that  the  association  of  the  two  diseases  is  either  accidental 
or  actually  founded  on  erroneous  diagnosis. 

Age. — Genito-urinary  tuberculosis  is  a  disease  of  young  adult  life. 
It  is  commonest  between  the  ages  of  15  and  40,  though  congenital  cases 
both  of  renal  and  of  epididymal  tuberculosis  have  been  reported,  and 
George  Walker's  table  of  375  cases  shows  29  above  the  age  of  50. 

The  Progress  of  the  Lesions. — In  the  urinary  tract  the  tuberculosis, 
beginning  in  the  kidney,  descends  to  the  ureter,  infects  the  bladder 
and  perhaps  the  prostate,  and  then  may  ascend  to  the  opposite  kidney. 
In  the  genital  tract,  beginning  in  the  prostate  or  vesicles,  it  extends  first 
to  one  epididymis,  and  often  later  to  the  other,  while  the  bladder  may 
be  infected  directly  from  the  prostate.  Urethral  and  penile  infection  is 
extremely  rare. 

"■Am.  Jour,  of  Urol.,  December,  ]9n,  vii,  459;  Boston  Med.  c^-  Surg.  Jour.,  June 
19,   1913,   clxviii,   923.  ''Lancet,   1913,   clxxxiv,   435. 

^Am.  Jour,  of  Med.  Sciences,  April,  1915,  cxlix,  535. 
*  Therapie  der  Gegenwart,  December,  1910,  li,  No.  12. 


CHAPTER    XLIII 
TUBERCULOSIS  OF  THE  KIDNEY 

PATHOLOGY 

Tuberculosis  causes  three  recognized  types  of  pathological  change 
in  the  kidneys : 

Acute  miliary  tuberculosis. 
Surgical  tuberculosis. 
Toxic  tuberculous  nephritis. 

ACUTE    MILIARY    TUBERCULOSIS 

Miliary  tuberculosis  of  the  kidney  is  but  a  part  of  general  visceral 
tuberculosis.     It  has  no  interest  for  the  surgeon. 

SURGICAL  TUBERCULOSIS 

Chronic  or  surgical  renal  tuberculosis  begins  and  develops  as  a 
characteristically  localized  and  unilateral  disease.  Infection  of  the 
opposite  kidney  is  usually  surprisingly  slow  to  develop.  Halle  and 
Motz  found,  for  instance,  in  131  post  mortem  examinations,  89  unilat- 
eral cases  of  renal  tuberculosis.  The  first  lesion  of  chronic  renal 
tuberculosis  usually  appears  near  the  base  of  one  of  the  papillae  ^  at 
the  upper  or  lower  pole  of  the  kidney ;  the  central  portion  of  the 
parenchyma  is  singiilarly  exempt  from  involvement.  This  first  lesion 
is  a  characteristic  tubercle,  crowded  with  tubercle  bacilli.  The  lesion 
spreads  by  three  methods : 

1.  The  lesion  itself  enlarges  by  extension  of  round-cell  infiltration 
which  ultimately  breaks  down  to  form  a  cheesy  nodule  or  cyst ;  or  if  it 
reaches  the  kidney  pelvis  a  tuberculous  ulcer. 

2.  Lymphatic  absorption  gives  rise  to  new  tuberculous  foci  in  vari- 
ous parts  of  the  kidney  (notably  distributed  in  wedge  shape  from  the 
original  lesion  toward  the  kidney  cortex).  These  tubercles  in  turn 
coalesce  and  break  down. 

3.  In  the  meanwhile,  toxic  tvherculous  nephritis  affects  portions  of 

K;f.  Ekehorn,  Nord.  med.  Arlc,  1914,  xlvii,  No.  12.  And  Wildboltz,  Zeitschr. 
f.  Urol.  Chir.,  1914,  ii,  201. 

416 


PLATE    XIV 


Fig.  1 


Fig. 


Renal  Tuberculosis. 

Fig.  1. — Early  Renal  Tuberculosis.  Uppermost  papillae  ulcerated.  Pelvis  already- 
much  contracted.     Ureter  only  slightly  involved. 

Fig.  2. — Complete  Caseation  of  Kidney,  Pelvis  and  Ureter.  Nephrectomy  to  relieve 
bladder  symptoms  due  to  drag  of  shortened  ureter. 


Fig.  87. — Renai,  Tuberculosis.     Upper  pole   a  mass    of    tuberculous   tissue;   lower 
pole    pyonephrotic ;    pelvis    obliterated. 


> 


« 


if; 


^  .1 


Fig.  88. — Renal  Tuberculosis.     Abscesses  throughout,  but  chiefly  at  poles;  fibrolipoma- 
tous and  suppurating  perinephritis;  ureter  obliterated. 


417 


418 


TUBERCULOSIS  OF  THE  KIDNEY 

/ 


the  kidney  not  infaded  fey  the  actual  tuberculosis  and  also  ultimately 
affects  the  opposite  kidney. 

In  the  renal  pelvis  and  uretei'  the  tuberculous  lesions  begin  as  local- 
ized superficial  ulcerations  or  a  generalized  infiltration  which  gives  the 
surface  of  the  ureter  and  pelvis  a  pebbled  appearance.  The  inflamma- 
tion soon  extends  to  all  the  coats  of  the  ureter  causing  a  sclerosis  and 


Fig.  89. — Renal  Tuberculosis.     Abscesses  at  upper  (T)  and  lower  poles  with  renal  tissue 
(R)  between.     Pelvis  obliterated ;  ureter  (U)  thickened  and  dilated. 


fibrolipomatous  periureteritis  and  peripyelitis.^  The  ureter  is  thus 
much  thickened,  its  lumen  narrowed  and  strictured  and  its  elasticity 
lost.  If  it  is  thus  shortened,  its  vesical  orifice  is  retracted,  its  peristalsis 
lost. 

The  usual  ultimate  result  of  these  various  lesions  is  total  destruction 
by  ulceration  of  the  greater  part. of  the  parenchyma,  so  that  in  spite  of 
thickening,  ulceration  and  contraction  of  the  actual  pelvis,  the  cavity 

*  Halle  and  Motz,  Guyon's  Annal.,  1906,  xxiv,  No.  3  and  4. 


Fig.   1 


Fig.  2 
Renal  Tuberculosis. 

Fig.  1. — Beginning  Tuberculous  Hydronephrosis.      Ureter   obliterated.      Parenchyma 

destroyed  by  ulceration.     Pelvis  dilating. 
Fig.  2. — Terminal  Stage.    Kidney  caseous,  atrophied,  sclerotic.    Capsule  (stripped  back) 
extensively  tuberculous.     Ureter  much  thickened. 


PATHOLOGY 


419 


of  the  kidney  is  enlarged  into  a  multiloenlar  pyonephrotic  sac ; 
while  the  remaining  parenchyma  is  little  better  than  scar  tissue, 
and  the  whole  is  snrronnded  by  a  dense  mass  of  fibrolipomatous  peri- 
nephritis. 

Out  of  these  various  lesions  it  is  quite  fruitless  to  attempt  the  de- 
scription of  pathological  types.  In  the  early  stages  the  papillary  or 
pyelitic  ulcer  may  predominate  (indeed  the  tuberculosis  is  sometimes 
spoken  of  as  primary 
in  the  kidney  pel- 
vis ^),  or  the  miliary 
type  may  predomi- 
nate, or  the  diffused 
tuberculoma ;  while 
toward  the  termina- 
tion of  the  disease  the 
prevailing  lesions  are 
those  just  described 
(ulcero  -  cavernous 
type)  or  there  may 
be  large  cysts  or 
cheesy  foci  or  tuber- 
culous hydronephro- 
sis. 

PerinepJiritic  ab- 
scess is  extremely  un- 
common. Mixed  in- 
fection is  unusual  in 
the  tuberculous  kid- 
ney, but  A  pyogenic 
infection  is  not  an 
unconimon  occur- 
rence   in    its    fellow. 

Bladder  invasion 
results  by  direct  ex- 
tension of  the  disease 
from     the    ureter 

mouth  to  the  adjoining  region,  notably  the  trigone.  Thence  it  spreads 
to  the  orifice  of  the  urethra  (involving  the  prostate  in  the  male)  and 
of  the  opposite  ureter.  Thus  the  renal  lesion  extends  to  the  male 
genitals,  and  thus  it  may  stricture  the  orifice  of  the  opposite  ureter 
and  cause  hydronephrosis  of  the  non-tuberculous  kidney. 

Whether   the   opposite   kidney  becomes   infected  by   ascending  or 
descending  invasion  is  not  proven. 

^Buerger,  Interstate  Med.  Jour.,  1914,  xxi,  No.  11. 


Fig.  90. — Renal  Tuberculosis.  Terminal  Stage.  Large 
cheesy  focus  above.  Ulcerating  and  sclerotic  lesions  else- 
where.    Pelvis  obliterated.     Ureter  thick. 


420  TUBERCULOSIS  OF  THE  KIDNEY 


TOXIC  NEPHRITIS 


Parenchymatous  nephritis  of  the  opposite  kidney  is  very  common. 
It  may  deliver  a  high  percentage  of  albumin  and  many  casts.  This 
lesion,  far  from  being  a  contra-indication  to  nephrectomy,  is  actually 
curable  only  by  this  operation. 


SYMPTOMS 

The  symptoms  of  renal  tuberculosis  usually  make  their  first  appear- 
ance between  the  fifteenth  and  the  thirty-fifth  year. 

The  disease  is  very  uncommon  in  childhood ;  indeed  Oraison  ^  has 
been  able  to  collect  only  51  cases  of  renal  tuberculosis  in  children. 
Statistical  reports  derived  from  the  autopsy  table  show  a  very  large  per- 
centage of  renal  tuberculosis  at  a  relatively  advanced  age.  This  is 
due  to  the  remarkably  chronic  course  of  certain  cases  which  may  run 
from  fifteen  to  twenty-five  years,  or  if  actually  occluded,  indefinitely. 

Clinical  Types. — Three  clinical  types  of  the  disease  are  recognized, 
the  predominant  feature  of  which  are  the  following : 

Frequent  and  painful  urination. 

Hematuria. 

Renal  pain  or  colic. 

ISJ"one  of  these  types  is  exclusive.  Almost  every  case  of  renal 
tuberculosis  has  frequent  and  painful  urination  as  its  predominating 
feature ;  almost  every  case  has  some  hematuria  at  one  time  or  another ; 
renal  pain  is  a  relatively  rare  symptom. 

The  Bladder  Type. — The  mere  presence  of  a  tuberculous  focus  in 
the  kidney  causes  no  symptoms  beyond  perhaps  slight  fever  and  poly- 
uria. When  such  a  focus  bursts  into  the  pelvis  it  is  likely  to  cause  a 
slight  brief  hemorrhage.  (This  often  passes  unnoticed.)  The^^isease 
then  spreads  to  the  kidney  pelvis  and  ureter,  causing  painful  and 
frequent  urination  even  before  the  bladder  is  infected.  The  bladder 
is  soon  invaded,  however,  and  adds  to  the  intensity  of  the  symptoms. 

Frequent  and  Painful  Urination.- — At  first  the  frequency  of 
urination  is  definitely  more  marked  by  night  than  by  day,  and  is  accom- 
panied by  polyuria  which  is  also  more  marked  by  night.  Ureteral 
catheterization  at  this  early  stage  will  show  a  marked  polyuria  from 
the  diseased  kidney.  The  total  excretion  of  urea  may  even  be  greater 
from  the  diseased  kidney,  though  its  phenolsulphonephthalein  output 
is  always  less.     (I  have  seen  but  one  exception  to  this  rule.) 

Pain  may  be  felt  before,  during,  or  after  micturition.  But  the 
most  marked  and  characteristic  pain  is  terminal  (occurring  at  the  end 

Wour.  d'Urol,  1913,  iv,  No.  1. 


SYMPTOMS 


421 


of  micturition  and  continuing  for  some  time  thereafter).  When  inten- 
sified by  lesions  of  the  trigone,  this  terminal  pain  may  be  associated 
with  terminal  hematuria. 

Hematuria. — The  hematuria  of  renal  tuberculosis  assumes  three 
forms  which  we  may  describe  in  order  of  their  frequency : 

Microscopic  hematuria  (a  few  red  blood  cells  and  a  trace  of  albu- 
min) occurs  from  time  to  time  in  all  cases. 

Slight  visible 
hematuria  (either  a 
smokiness  in  the  urine 
or  more  commonly  a 
distinctly  terminal 
hematuria)  is  likely  to 
occur  as  soon  as  the 
bladder  has  become 
considerably  infected. 
Later,  this  usually 
ceases. 

Massive  hematuria 
(renal  hemoptysis,  as 
it  has  been  called)  is 
rare ;  but  it  may  domi- 
nate the  scene.  It  oc- 
curs early,  like  pulmo- 
nary hemoptysis,  and 
in  the  absence  of  other 
symptoms  may  suggest 
neoplasm. 

Renal  >  Pain  and 
Colic.  —  Renal  pain, 
while  not  nearly  so 
common  a  symptom  of 

renal  tuberculosis  as  hematuria,  bears  much  the  same  relation  to  the 
clinical  picture.  Moderately  severe  loin  pain,  associated  with  tender- 
ness of  the  kidney,  occurs  in  perhaps  50  per  cent  of  cases.  Renal  colic 
is  rare,  but  may  occur  at  any  time  from  the  passage  of  blood  clots  or 
shreds  of  tissue  through  the  narrowed  ureter.  Renal  pain,  or  colic 
sufficiently  severe  to  dominate  the  scene  is  unusual. 

Crossed  Pain, — Renal  pain  may  occur  in  the  healthy  kidney  as  a 
result  of  compensatory  hypertrophy  of  that  organ.  On  the  other  hand 
severe  pain  in  the  opposite  loin  may  be  due  to  lesions  entirely  inde- 
pendent of  the  renal  tuberculosis.  One  of  my  cases  had  frightful  ronal 
colics  of  this  type  which  were  apparently  due  to  tuberculous  seminal 
vesiculitis. 


^V^^"^^! 

^H|[H| 

W^'"'    #• 

T^^^^^^^^^^^^H 

^H 

^n^^^^^l 

1 

v^H 

^ 

1      •-'>-^ 

mm 

Fig.  91. — Renal  Tuberculosis.  Complete  destruction  by 
sclerosis;  yet  the  only  symptom  had  been  hematuria, 
twice  in  six  years  from  the  ulcerated  papilla  at  lower  pole. 


422  TUBERCULOSIS  OF  THE  KIDNEY 

Fevee  and  General  Symptoms. — Slight  fever  and  slight  loss  of 
weight  doubtless  occur  from  time  to  time  in  all  cases  of  renal  tuber- 
culosis; but  marked  fever  is  rare  and  considerable  loss  of  weight  is 
due  either  to  bilateral  tuberculosis  or  to  toxemia  from  ureteral  retention. 
So  long  as  retention  is  absent  and  the  infection  unilateral,  the  patient 
may  apparently  enjoy  the  most  robust  health.  I  shall  never  forget 
the  first  vision  I  had  of  a  certain  woman,  subsequent  operation  upon 


Fig.  92. — Renal  Tuberculosis.     Upper  half  of  kidney   cystic  and   caseous;   yet  ureter 
spared.     Symptoms  wholly  toxic  (digestive).     Treated  for  years  as  dyspeptic. 

whom  proved  her  to  harbor  a  completely  destroyed  pyonephrotic  tuber- 
culous kidney.  As  her  250  pounds  lay  in  a  hospital  bed,  surrounded 
by  her  anxious  family,  she  apparently  weighed  as  much  as  all  the 
rest  of  them  put  together.  But  late  in  the  disease  the  ureteral  lesions 
are  such  that  adequate  drainage  of  the  kidney  is  the  exception.  Con- 
siderable loss  of  weight,  with  slight  fever,  is  the  rule.  Such  is  our 
interpretation  of  Israel's  statement  that  he  found  fever  in  only  15  per 
cent  of  uncomplicated  renal  cases,  but  in  80  per  cent  of  the  cases  com- 
plicated by  bladder  infection. 

PHYSICAL  SIGNS 

The  Urine — Pus  is  practically  constant  in  the  urine  in  sufficient 
quantity  to  cloud  it.     I  have  failed  to  find  it  only  twice ;  once  in  a  case 


SYMPTOMS  423 

of  intermittent  profuse  hematuria,  due  to  a  small  papillary  ulceration, 
the  other  time  in  a  case  of  closed  pyonephrosis  that  was  delivering 
no  urine  whatever. 

Albumin  is  equally  constant ;  usually  a  trace.  The  presence  of  an;y 
appreciable  percentage  of  albumin  usually  means  grave  toxic  nephritia 
of  the  opposite  kidney,  and  is  accompanied  by  casts.  In  the  absence 
of  this  toxic  nephritis  casts  are  not  likely  to  be  found. 

Blood  is  commonly  present  in  microscopic  quantity,  and  fully  half 
the  cases  give  a  history  of  gross  hematuria. 

A  striking  feature  of  the  urine  is  that  it  is  likely  to  be  sterile  on 
ordinary  culture  media  (if  drawn  from  the  bladder)  even  though  defi- 
nitely purident.  Such  a  sterile  purulent  urine  is  likely  to  be  caused 
only  by  the  tubercle  bacillus  or  the  gonococcus.  Bacillus  coli  or  other 
infection  of  the  opposite  kidney  is,  however,  present  in  a  large  minority 
of  cases. 

The  urine  is  acid  unless  rendered  alkaline  by  mixed  infection. 

Tuberculous  Lesions  Elsewhere  in  the  Body. — At  the  time  of  the 
first  examination  the  bladder  will  be  found  infected  in  about  90  per 
cent  of  cases,  the  opposite  kidney  in  from  10  to  20  per  cent.  Slight 
prostatic  infection  doubtless  occurs  early  in  many  men,  but  is  usually 
overlooked.  The  infection  reaches  the  epididymis  in  only  a  small 
percentage  of  cases. 

Radiographic  evidence  of  tuberculosis  in  the  lungs  is  usually  obtain- 
able though  the  clinical  history  is  often  silent  on  this  point.  Bone  and 
gland  tuberculosis  are  rare  complications.  It.  has  been  noted  that  a 
singularly  large  proportion  of  patients  with  genito-urinary  tubercu- 
losis die  of  tuberculous  meningitis. 


Diagnosis 

It  is  impossible  to  make  a  full  diagnosis  of  renal  tuberculosis  with- 
out the  ureter  catheter.     The  diagnosis  must  cover  the  following  points : 

(1)  The  presence  of  urinary  tuberculosis;  (2)  The  origin  of  this 
tuberculosis  in  the  kidney  or  in  the  prostate;  (3)  If  in  the  kidney, 
which  kidney  is  involved;  (4)  If  one  kidney  is  involved,  what  is  the 
condition  of  its  fellow;  (5)  Are  there  active  lesions  of  tuberculosis  else- 
where ? 

The  suspicion  of  renal  tuberculosis  is  aroused  whenever  there  is 
spontaneous  cystitis  or  prolonged  pyuria,  or  bleeding  great  or  small  in 
a  relatively  young  person.  This  suspicion  is  strengthened  if  the  urine 
is  acid,  free  from  bacteria,  yet  purulent,  and  contains  a  trace  of  albu- 
min, and  microscopic  or  macroscopic  blood.  If  the  tubercle  bacillus  is 
found  in  the  urine  (see  below)  the  existence  of  tuberculosis  somewhere 
in  the  urinary  organs  is  proven.     The  palpably  large  or  tender  kidney 


424  TUBERCULOSIS  OF  THE  KIDNEY 

may  be  tuberculous,  or  it  may  be  the  hypertrophied  or  bj^dronephrotic 
opposite  kidney.  If  the  radiograph  shows  a  marked  diiTerence  in  the 
size  of  the  two  kidneys,  the  large  kidney  is  usually  the  normal  one  in 
compensatory  hypertrophy;  for  tuberculous  pyonephrosis  is  usually 
small.     Such  are  the  hints — the  proofs  follow: 

The  Tubercle  Bacillus. — In  order  to  minimize  contamination,  espe- 
cially with  the  acid-fast  smegmia  bacillus,  the  urine  should  be  drawn 
by  catheter  from  the  bladder  (or  the  ureters).  Bladder  contamination 
with  smegma  bacilli  is  said  not  to  be  possible,  yet  I  have  twice  been 
temporarily  misled  by  the  report  of  acid-fast  bacilli  morphologically 
resembling  the  tubercle  bacillus  obtained  from  bladder  urine,  and  re- 
ported by  a  laboratory  of  good  repute.  So  far  as  I  know  this  mistake 
does  not  occur  if  the  all-night  decolorization  is  employed. 

In  early  and  active  cases  the  tubercle  bacilli  are  usually  found 
readily  and  in  large  numbers.  But  in  all  cases  it  may  be  difficult  to 
identify  them  both  on  account  of  their  scarcity  and  on  account  of 
mixed  infection:  nephritis,  etc.  The  antiformin  and  other  methods  of 
cleansing  the  urine  are  of  some  assistance  in  obviating  this  difficulty; 
the  best  method  is  probably  that  suggested  by  Crabtree  ^  of  centrifuging 
a  numl^er  of  tubes  full  of  urine  at  the  usual  300  revolution  rate  for  3 
minutes,  thus  throwing  down  practically  all  of  the  pus,  then  centrifug- 
ing again  at  1,000  revolutions  until  the  urine  is  clear,  thus  throwing 
down  the  bacteria  relatively  uncontaminated. 

Were  it  not  for  the  delay  involved,  the  accu-racy  of  the  giiinea-pig 
injection  test  for  tuberculosis  would  make  this  the  test  of  choice  in  all 
cases ;  but  two  or  three  months  is  a  long  time  to  wait  for  a  diagnosis, 
and  though  this  period  may  be  shortened  by  various  devices,  such  as 
injecting  the  urine  subcutaneously  in  the  thigh  of  the  pig  and  bruising 
its  inguinal  glands,  these  devices  are  not  regarded  as  entirely  safe  by 
the  best  laboratory  workers. 

With  typical  clinical  history,  and  cystoscopic  and  ureter  catheter 
findings,  the  usual  over-night  stain  suffices  for  a  diagnosis.  Indeed, 
even  the  guinea-pig  may  err.  I  have  had  two  cases  in  which  the  tem- 
porary closing  of  the  renal  focus  of  infection  permitted  negative  guinea- 
pig  reports  which  were  subsequently  repudiated  by  relapse  of  symptoms, 
correct  diagnosis,  and  nephrectomy. 

Cystoscopy — The  alert  expert  will  not  fall  into  the  error  of  con- 
sidering every  patchy  or  ulcerative  cystitis  tuberculous,  nor  will  he  be- 
lieve a  kidney  tuberculous  because  its  ureter  mouth  is  inflamed  (for  the 
kidney  above  may  be  normal)  or  ulcerated,  deformed  or  retracted  (for 
the  kidney  above  may  be  the  seat  of  non-tuberculous  inflammation). 
Indeed  there  is  nothing  absolutely  characteristic  about  the  appearance 
of  a  severe  tuberculous  cystitis,  nor  anything  to  prove  that  it  is  derived 

^  Surg.,  Gynec.  and  Ohstet.,  March,  1915. 


SYMPTOMS  425 

from  a  primary  lesion  in  the  prostate  or  in  either  kidney.  Early  cys- 
titis is  often  more  suggestive  in  that  it  shows  a  strikingly  patchy  dis- 
tribution of  lesions,  their  tendency  to  group  in  the  region  of  the  ureter 
affected,  and  the  appearance  of  characteristic  little  nodules  (the  so- 
called  tubercles). 

Tubercle  Bacilli  without  Pus — Although  pus  (and  even  bacilli) 
may  be  absent  for  brief  periods  from  the  urine  of  patients  with  small 
surgical  lesions^  the  presence  in  the  urine  of  bacilli  without  pus  does  not 
establish  the  existence  of  renal  tuberculosis.  Sufferers  from  advanced 
pulmonary  tuberculosis  often  deliver  bacilli  in  the  urine,  though  subse- 
quent post  mortem  shows  no  renal  lesion. 

Excision  of  a  Piece  of  Mucous  Membrane ^When  the  tubercle 

bacillus  is  not  found  in  the  urine  a  positive  diagnosis  may  often  be  made 
(as  suggested  by  Buerger)  by  microscopic  examination  of  a  piece  of 
mucous  membrane  removed  through  the  operating  cystoscope. 

But  the  localization  of  the  lesion  and  the  establishment  of  the  con- 
dition of  the  opposite  kidney  require  ureter  catheterization. 

Ureter  Catheter  Diagnosis — The  catheters  are  introduced  into  the 
renal  pelves  in  order  to  estimate  the  presence  of  retained  urine  there. 

The  first  urine  obtained  is  discarded  in  order  to  avoid  contamination 
with  pus  that  may  have  been  picked  up  in  the  bladder. 

The  next  few  c.c.  are  employed  for  the  usual  urea  and  microscopic 
examination,  following  which  the  intravenous  phenolsulphonephthalei a 
estimation  is  made. 

In  early  cases  a  distinct  polyuria  from  the  diseased  side  will  bo 
noted,  the  increase  in  quantity  being  sometimes  sufficient  to  counter- 
balance the  lowered  urea  percentage  so  that  the  total  amount  of  urea 
secreted  at  any  one  time  by  the  diseased  kidney  is  gi-eater  than  that 
secreted  by  the  normal  kidney.  But  the  phenolsulphonephthalein  out- 
put is  much  more  markedly  interfered  with  and  clearly  shows  a  defi- 
ciency on  the  side  of  the  diseased  kidney  (only  once  have  I  known  this 
to  fail ;  six  months  later  a  second  cystoscopy  showed  a  distinct,  though 
slight,  falling  off  of  phenolsulphonephthalein  output,  and  nephrectomy 
revealed  a  destruction  of  a  single  papilla  by  tuberculosis).  In  these 
early  cases  the  tubercle  bacillus  is  usually  readily  identified. 

When  the  disease  is  further  advanced,  one  recognizes  readily  enough 
the  presence  of  pus  and  the  marked  lowering,  both  of  phenolsul- 
phonephthalein and  urea  output.  But  the  identification  of  the  tubercle 
bacillus  may  present  considerable  difficulties.  In  such  cases  the  exci- 
sion of  a  piece  of  vesical  mucous  membrane  is  likely  to  prove  useful. 

When  the  ureter  mouths  cannot  be  found,  intravenous  injection  of 
indigocarmin  is  a  gTeat  help,  both  in  suggesting  which  is  the  more 
normal  kidney  and  in  aiding  the  passage  of  the  ureter  catheter.  Dif- 
ficulty in  cystoscopy,  due  to  the  great  sensitiveness  of  the  bladder,  must 


426 


TUBERCULOSIS  OF  THE  KIDNEY 


be  overcome  by  various  forms  of  anesthesia.  General  anesthesia  is  most 
inadvisable.  The  recovery  from  ether,  given  for  the  purpose  of  cystos- 
copy, is  much  more  trying  and  dangerous  than  when  the  ether  is  given 
for  the  purpose  of  nephrectomy ;  for  in  the  latter  case  the  patient  is  at 
least  relieved  of  his  toxic  focus.  I  have  employed  spinal  anesthesia 
with  gTcat  satisfaction,  but  have  had  no  luck  with  sacral  anesthesia. 
My  present  preference  in  the  management  of  these  cases  is  to  administer 

h  y  0  c  i  n  and  morphin, 
then  an  intravenous  in- 
jection of  indigocarmin, 
and  a  local  anesthetic. 
I  then  employ  the  18 
F.  single  catheter  cysto- 
scope,  direct  this  imme- 
diately toward  the  ureter 
mouth,  from  which  I  ex- 
pect to  see  the  blue 
stream  issue;  if  this  ap- 
pears, catheterize  that 
ureter  immediately  with- 
rut  looking  for  anything 
else;  if  it  does  not  ap- 
pear, turn  immediately 
to  the  other  side  and 
catheterize  that  ureter. 
By  this  combination 
(anesthesia  and  the  use 
of  a  small  cystoscope)  a 
skillful  manipulator  can 
catheterize  one  ureter 
with  scarcely  more  pain 
than  would  be  involved 
in  the  introduction  of  a  catheter.  Unless  the  patient  is  unusually 
intolerant  the  cystoscope  may  be  left  in  place  so  that  through  it  the 
water  in  the  bladder  can  be  drawn  off  as  it  accumulates  for  comparison 
with  the  urine  obtained  through  the  ureter  catheter. 

If  all  these  means  of  diagnosis  fail,  we  must  await  the  guinea-pig 
for  an  absolute  diagnosis  of  tuberculosis.  Once  this  is  obtained,  if 
there  is  good  reason  to  believe  that  one  of  the  kidneys  is  normal,  or 
relatively  normal,  the  selection  of  kidney  for  nephrectomy  may  be 
intrusted  to  exploratory  operation.  It  may  be  necessary  to  disclose 
the  surface  of  both  kidneys  completely,  or  even  in  some  instances  to 
palpate  both  ureters  before  the  diagnosis  can  be  made.  A  tuberculous 
kidney  always  shows  a  relatively  thickened  ureter. 


Fig.  93. — Renal  Tuberculosis.  Remission  of  symp- 
toms three  years  (note  obliteration  of  pelvis  adjacent 
to  old  lesion).  Negative  guinea-pig.  Then  recur- 
rence of  bladder  symptoms.    Diagnosis  by  Fig.  94. 


SYMPTOMS  427 

Other  Means  of  Diagnosis. — There  are  many  means  of  diag-nosis  of 
secondary  importance  as  confirmatory  of  the  findings  enumerated  above. 
Amonff  them  the  followins;  mav  be  mentioned : 

The  thickened  tuberculous  ureter  may  often  be  palpated  through 


Fig.  94. — Pyelogeam  of  Fig.  93.     Cystic  lower  pole  shows  well,  also  obliteration  of  lower 
half  of  pelvis  and  deformity  of  upper  half. 

the  vagina.     (I  have  once  known  a  competent  urologist  to  feel  such  a 
ureter  very  distinctly  when  it  was  not  there!) 

Pyelography  outlines  very  di.stinctly  the  deformity  in  the  kidney 
pelvis  produced  by  the  destruction  of  tuberculosis  (Figs.  98  to  00). 
But  tuberculosis  is  one  of  the  conditions  in  which  I  feel  least  faith  in 
employing  pyelography.     The  radiogram  without  pyelography  does  not 


428 


TUBERCULOSIS  OF  THE  KIDNEY 


distinguish  between  the  shadow  cast  by  a  cheesy  kidney  and  the  shadow 
cast  by  a  hydronephrosis  (Ph  XVI). 

The  tuberculosis  complement  fixation  test  for  urine  is  highly  spoken 
of  by  Heitz-Boyer.^     I  have  vainly  tried  to  duplicate  his  results. 

Beer  -  places  much  dependence  upon  the  diagnostic  tuberculin 
injection  to  identify  the  presence  of  tuberculosis  in  the  body.     A  focal 


Fig.  95. — Pyelogram  of  Fig.  96. — Irregular  pelvis.     Tuberculous  ulcerations  in  parenchyma 

filled  with  collargol. 

reaction  consisting  in  pain  and  tenderness  (and  often  an  increase  of 
tubercle  bacilli  in  the  urine)  identifies  the  situation  of  the  lesion.  He 
believes  the  drug  safe  if  used  with  proper  restrictions. 


Prognosis 

The  progress  of  renal  tuberculosis  may  be  so  rapid  that  within  a 
few  months  life  is  rendered  almost  unendurable,  or  the  symptoms  may 
remain  quite  bearable  for  many  years.     The  general  health  remains 

^Jour.  d'Urol.,  Jan.  15,  1912,  ii,  71.  ""Med.  Becord,  1913,  Ixxxiv,  650. 


PLATE    XVI 


Fig.  1 


Fig.  2 
Radiography  of  Renal  Tuberculosis  and  Hydronephrosis. 

Fig.  1. — Hydronephrosis.     (Not  a  pyelogram.     The  gross  specimen  removed  after  pyelog- 
raphy is  shown  in  Fig.  39.) 
Fig.  2. — Caseous  Rknal  Tuberculosis.     (Not  a  pyelogram.) 


SYMPTOMS 


429 


good  unless  retention,  bilateral  renal  lesion  or  complications  impair  it. 
Long  periods  of  remission  may  occur,  but  the  progress  is  generally 
downward.     Nephrectomy  is  the  only  relief. 

Treatment 

Wildbolz  ^  records  his  own  conversion  from  medical  to  surgical  treat- 
ment in  convincing  fashion.  He  cites  78  cases  who  three  years  after 
nephrectomy  were  divided  as  follows:    59  per  cent  alive  and  cured,  21 


Fig.  96. — Renal  Tuberculosis  (and  Gonorrhea)  after  Pyelography.  Only  gonococci 
had  been  obtained  from  this  kidney  until  after  pyelography.  Then  acid-fast  bacilli  were 
found. 

per  cent  alive  but  tuberculous,  20  per  cent  dead.  To  compare  with 
these,  he  collected  316  cases  under  observation  at  various  sanatoria  in 
Switzerland;  70  per  cent  of  these  had  died  within  two  years,  and  of 
the  98  survivors,  68  still  suffered  from  urinary  tuberculosis,  while  only 
30  had  been  relieved  of  their  symptoms.  In  16  of  these  the  clinical 
cure  had  persisted  for  over  five  years,  but  after  years  of  apparent  cure 
sudden  breakdown  and  death  were  known  to  have  occurred. 

The  classical  contribution  on  nephrectomy  for  tuberculosis  is  that 
of  Israel.^     He  collected  1,023  nephrectomies  with  a  mortality  of  13 

^  Correspondenz-Blatt  f.  Schweitzer  Aerzte,  Dec.  20,  1912,  xli,  1265.  . 


430  TUBERCULOSIS  OF  THE  KIDNEY 

per  cent  in  tlie  first  six  months,  and  as  many  more  later  (half  of  the 
later  mortality  occurring  in  the  period  between  the  first  six  months 
and  the  end  of  the  second  year,  and  due  chiefly  to  pulmonary  tuber- 
culosis, renal  disease,  and  acute  miliary  tuberculosis). 

The  Mayos  up  to  1912  had  performed  203  nephrectomies  for  tuber- 
culosis with  an  immediate  hospital  mortality  of  2.9  per  cent.  Crabtree 
reports  103  cases  from  Cabot's  clinic  with  an  immediate  mortality  of 
3.8  per  cent.  I  have  performed  65  nephrectomies  for  tuberculosis  with 
2  deaths  before  the  patients  left  the  hospital,  and  3  more  during  the 
first  six  months  thereafter. 

Aftertreatment. — The  aftertreatment  must  cover  the  patient's  gen- 
eral condition,  the  persisting  tuberculous  cystitis  and  the  loin  sinus. 

Nephrectomy  is  only  the  foundation  stone  of  a  cure.  With  it  the 
cure  begins,  but  this  will  not  proceed  unless  the  nephrectomy  is  fol- 
lowed by  an  intelligent  course  of  antituberculosis  hygiene — a  compound 
of  fresh  air  and  overfeeding  and  the  intelligent  use  of  tuberculin.  This 
course  may  be  profitably  continued  for  at  least  a  year,  even  in  the 
most  favorable  cases. 

The  rules  for  the  treatment  of  tuberculous  cystitis — if  this  continues 
to  annoy  the  patient — are  laid  down  in  the  next  chapter. 

A  loin  sinus  persists  for  at  least  two  or  three  months  after  at  least 
50  per  cent  of  nephrectomies  for  tuberculosis.  Its  healing  may  be 
hastened  by  cutting  down  granulations  and  use  of  the  Beer  cup.  Ex- 
ceptionally the  whole  wound  will  break  down  and  become  tuberculous ; 
in  this  event  no  complete  healing  may  be  expected  within  one  or  two 
years.  I  have  known  such  wounds  to  remain  open  for  three  years,  and 
to  heal  at  the  end  of  that  time.    Heroic  measures  do  not  hasten  healing. 

Contra-indications  to  Nephrectomy — The  contra-indications  may 
be  found  in  the  opposite  kidney  or  in  other  organs.  Of  the  general 
contra-indications  to  nephrectomy  we  need  only  mention  active  tuber- 
culosis elsewhere  in  the  body,  and  myocarditis.  I  have  never  been 
deterred  from  performing  nephrectomy  by  the  fact  that  the  patient's 
lungs  showed  signs  of  apparently  healed  tuberculosis.  Indeed  I  have 
once  performed  nephrectomy  successfully  under  local  anesthesia  in  the 
face  of  a  rather  active  pulmonary  tuberculosis.  In  one  other  case, 
however,  my  medical  counsel  declared  the  patient's  lungs  quiescent;  I 
removed  a  tuberculous  kidney,  and  the  patient  died  a  few  weeks  later  of 
his  pulmonary  disease.  In  another  case,  I  braved  a  mild  pulmonary 
lesion  and  the  patient  died  five  months  later. 

The  condition  of  the  patient's  circulation  is  of  the  utmost  impor- 
tance. A  rapid  pulse  before  operation  suggests  the  possibility  of  myo- 
carditis, and  the  propriety  of  a  preliminary  w^eek  in  bed  on  digitalis. 
I  lost  one  patient  on  the  third  day  after  operation  through  myocarditis, 

^  Folia.  Urolog.,  September,  1911,  vi. 


SYMPTOMS  43( 

and  have  nearly  lost  several  others.  Israel  regards  this  as  a  frequen; 
cause  of  postoperative  death. 

The  condition  of  the  opposite  kidney  is  also  important.  It  maj 
be  congenitally  deficient  (p.  532),  otherwise  diseased,  the  seat  of  tuber- 
culous nephritis  or  the  seat  of  active  tuberculosis.  I  have  never  knowu 
tuberculous  nephritis  to  be  a  valid  contra-indication  to  operation. 

Tuberculosis  of  tho  opposite  kidney  was  for  a  long  time  consid- 
ered a  contra-indication  to  nephrectomy.  This  it  certainly  is  not.  If 
there  is  no  gTeat  difference  between  the  functional  capacity  of  the 
two  kidneys  there  is  quite  obviously  no  reason  to  remove  either  one  of 
them.  But  if  one  is  gravely  infected,  the  other  only  slightly  involved, 
the  gravely  infected  kidney  should  be  removed.  I  have  had  the 
happiest  results  from  following  this  course  of  action ;  although  I  must 
confess  that  one  of  my  immediate  deaths  was  the  result  of  an  attempt 
to  help  the  patient  by  removing  a  kidney  which  after  all  was  not  much 
more  diseased  than  its  fellow. 

But  fully  half  of  the  cases  of  bilateral  tuberculosis  with  grave  uni- 
lateral involvement  will  not  only  survive,  but  will  be  greatly  improved 
by  operation.  They  may  grow  fatter  than  they  had  been  before  opera- 
tion, and  may  consider  themselves  practically  cured.  Their  death,  when 
it  does  come,  is  likely  to  come  quickly,  and  as  a  result  of  total  destruc- 
tion of  the  renal  parenchyma. 

Thus  one  patient  of  mine  wrote  me  a  letter  last  June,  thanking  me 
for  the  two  years  of  good  health  he  had  enjoyed  after  taking  an  equal 
leng-th  of  time  to  recover  from  his  operation ;  but  this  man  died  of  renal 
insufficiency  four  months  later.  Another  case,  one  of  renal  tuber- 
culosis for  eleven  years  before  operation,  survived  the  operation  four 
years.  At  the  end  of  the  third  year,  she  weighed  more  than  she  ever 
had  in  her  life,  and  was  all  but  well.  A  year  later  she  died  very 
peacefully  of  renal  insufficiency  and  pulmonary  tuberculosis. 

To  sum  up : — The  contra-indications  to  nephrectomy  for  tuber- 
culosis are: 

1.  Any  general  condition  contra-indicating  a  major  operation. 

2.  Active  tuberculosis  elsewhere  in  the  body  in  such  variety  as  to 
contra-indicate  a  major  operation.  This  includes  almost  all  cases  of 
pulmonary  tuberculosis. 

3.  Tuberculosis  of  the  opposite  kidney  so  far  advanced  as  to  impair 
its  phenolsulphonephthalein  elimination  below  30  per  cent,  per  hour, 
after  intramuscular  injection. 

4.  Any  other  kidney  lesion,  congenital  or  acquired,  markedly  reduc- 
ing the  function  of  the  kidney. 

5.  Marked  tuberculous  nephritis  of  the  opposite  kidney  or  tuber- 
culous myocarditis  sufficient  to  make  the  pulse  persistently  rapid  are 
warning  signs  but  not  contra-indications  to  operation. 


CHAPTER  XLIY 

TUBERCULOUS    AND    SIMPLE    ULCERATION    OF    THE   BLADDER- 
TUBERCULOSIS  OF  THE  PROSTATE  AND  SEMINAL  VESICLES 

TUBERCULOSIS  OF  THE  BLADDER 

ETIOLOGY 

TrBEECULOsis  of  tlie  bladder  is  almost  always  secondary  to  lesions 
in  the  kidney  or  in  the  prostate.  It  may  be  secondary  to  adjacent 
tuberculosis  in  other  organs.  But  this  is  most  exceptional.  Thus  Violer 
and  Chalier  ^  report  three  cases  of  rupture  of  tuberculous  adnexa  into 
the  bladder.  At  least  nine  out  of  ten  cases  of  bladder  tuberculosis  are 
secondary  to  kidney  lesions. 

Age.  — G.  Walker  -  collected  4Y5  cases  of  bladder  tuberculosis,  the 
great  majority  between  the  ages  of  15  and  40. 

PATHOLOGY 

Distribution  of  Lesions. — The  lesions  of  vesical  tuberculosis  begin 
about  the  ureter  if  the  disease  descends  from  the  kidney;  about  the 
bladder  neck  if  the  invasion  is  from  the  prostate ;  but  when  'the  case  is 
first  cystoscoped,  there  is  often  a  general  distribution  of  the  lesions 
about  the  trigone,  and  perhaps  about  the  rest  of  the  bladder,  which  pre- 
vents a  definite  diagnosis  from  cystoscopy  alone,  without  the  aid  of 
ureter  catheterization. 

If  there  is  mixed  infection,  the  whole  bladder  may  be  inflamed.  If 
not,  even  though  the  gTeater  part  of  the  organ  is  inflamed,  there  are 
usually  regions  in  which  the  normal  mucous  membrane  may  be  seen  at 
some  parts  of  the  vault  of  the  bladder. 

The  tubercles  appear  as  minute  raised  areas,  the  size  of  a  pinhead, 
surrounded  by  an  area  of  congestion.  They  are  usually  grouped  to- 
gether over  irregular  areas  of  the  bladder  wall,  while  between  them  the 
mucous  membrane  is  red,  swollen,  and  velvety.  Thus  a  diffuse  vesical 
tuberculosis  gives  the  whole  mucous  membrane  a  velvety  appearance. 
Although  the  tubercles  may  be  seen,  and  sometimes  even  felt,  through 
the  unbroken  epithelium,  the  initial  deposit  occurs,  as  Coplin  ^  has 

^Bev.  de.  Gynec,  1909,  xiii,  No.  1. 

'Annals  of  Surg.,  Feb.,  1907,  p.  249, 

'Jour,  of  Cut.  and  Gen.-Urin.  Dis.,  1898,  xvi,  557. 

432 


TUBERCULOSIS  OF  THE  BLADDER  433 

justly  remarked,  not  in  the  epithelium,  but  in  the  subepithelial  con- 
nective tissue. 

The  tuberculous  ulcer  "is  singularly  round  and  discoid.  .  .  .  Even 
the  confluent  ulcers  rapidly  lose  the  isthmus  which  at  one  time  partly 
separated  them  and  quickly  assume  a  roundish  outline.  The  floor  of  the 
ulcer  is  shaggy,  of  a  dirty  yellowish  color.  It  is  uneven  in  contour. 
.  .  .  Commonly  the  ulcer  does  not  become  larger  than  1  or  2  cm.,  or 
about  the  size  of  a  5-ccnt  piece.  The  floor  of  the  ulcer  is  the  submucosa 
containing  considerable  embryonic  tissue.  In  some  instances  and  at  a 
few  points  in  any  ulcer  the  muscular  wall  may  be  exposed.  ...  I  think 
extension  into  the  muscular  wall  must  be  rather  infrequent.  .  .  .  The 
edges  are  elevated  and  slightly  undermined  .  .  .  hard  to  the  touch" 
(Coplin). 

The  above  description,  written  from  the  point  of  view  of  the  pathol- 
ogist, is  entirely  in  accord  with  the  clinical  findings.  I  have  never 
known  perforation  of  the  bladder  to  occur  spontaneously ;  but  I  have 
twice  known  perforation  to  follow  cystoscopy.  The  great  irritability  of 
the  bladder— its  characteristic  inability  to  retain  more  than  a  few  ounces 
• — is  due  at  first  to  the  great  sensitiveness  of  the  tuberculous  lesions, 
later  to  an  actual  infiltration  and  contracture  of  the  muscular  walls. 

Individual  lesions  may  heal  while  others  progress.  The  removal 
of  the  tuberculous  kidney  is  usually  followed  by  the  healing  of  the  tuber- 
culous bladder  lesions  in  a  few  months  if  they  are  recent ;  in  a  few 
years  if  ancient  or  fed  by  tuberculous  prostatitis  or  stricture.       '♦ 

Direct  extension  of  the  inflammation  to  the  posterior  urethra  is 
common.  Extension  to  the  anterior  urethra  is  rare.  I  have  seen 
it  but  once.  Urethral  stricture  and  periurethral  abscess  are  rare  com- 
plications. V^"""--, 

SYMPTOMS 

The  symptoms  of  tuberculosis  of  the  bladder — frequent  and  pain- 
ful urination  and  hematuria,  profuse  or  terminal — and  its  urinary 
changes  form  so  essential  a  part  of  renal  tuberculosis  that  they  have 
been  described  in  the  preceding  chapter. 

Among  the  other  symptoms  due  to  tuberculous  cystitis  a  partial  in- 
continence of  urine  from  spasm  or  from  ulceration  of  the  neck  of  the 
bladder  is  notable.  Stricture  of  the  deep  urethra  may  cause  retention 
of  urine.  The  symptoms  of  involvement  of  the  other  genitourinary 
organs  are  sooner  or  later  important. 

DIAGNOSIS 

The  diagnosis  of  bladder  tuberculosis  belongs  even  more  intimately 
with  renal  -tuberculosis  than  do  its  symptoms.  For  the  diagnosis  of 
bladder  tuberculosis  is  only  interesting  insonnich  as  it  leads  to  a 
diagnosis  of  the  etiological  renal  or  prostatic  lesion. 


434  TUBERCULOSIS  OF  THE  BLADDER 

TREATMENT 

The  first  step  in  the  treatment  of  bladder  tuberculosis  is  discovery 
and  removal  of  the  offending  kidney. 

If  there  is  no  offending  kidney,  or  if  its  removal  is  contra-indicated, 
or  if  it  has  been  removed  without  benefit  to  the  bladder,  the  direct  at- 
tack on  the  bladder  begins. 

Conservative  treatment  of  tuberculosis  of  the  bladder  has  given  far 
better  results  than  any  of  the  radical  procedures  that  have  been  em- 
ployed. Whatever  local  or  operative  treatment  be  undertaken,  hygiene 
is  always  the  backbone  of  treatment.  Balsamics  modify  the  urine  and 
soothe  the  bladder.  Urinary  antiseptics  are  useless  and  likely  to  prove 
irritating. 

Tuberculin  injections  may  relieve  the  symptoms. 

Local  Treatment. — Local  treatment  is  employed  often  with  great 
success,  but  only  according  to  certain  well-defined  rules.  In  the  first 
place,  gentleness  is  more  essential  here  than  in  any  other  form  of 
urinary  disease.  In  the  second  place,  irrigations  must  not  be  used. 
They  are  very  badly  borne  by  the  sensitive  bladder  and  do  no  more 
good  than  instillations.  In  the  third  place,  nitrate  of  silver,  boric  acid, 
and  permanganate  of  potassium,  so  soothing  to  simple  cystitis,  cannot 
be  employed  in  tuberculous  cystitis  on  account  of  the  violent  reaction 
they  provoke  even  in  very  weak  solution- — this  is  especially  true  of  the 
silver  salts.  Finally,  the  best  rule  for  local  treatment  is  to  use  the  drug 
that  gives  the  most  comfort,  regardless  of  any  curative  powers  it  may 
possess. 

The  best  local  application  for  the  tuberculous  bladder  is  carbolic  acid, 
as  suggested  by  Eovsing.  But  his  treatment — irrigation  with  5  per 
cent  carbolic  acid  until  the  fluid  returns  clear — is  unnecessarily  pain- 
ful. As  good  results  may  be  obtained  by  daily  instillation  of  two  to 
twenty  drops  of  2  per  cent  solution  into  the  bladder  neck. 

I  have  also  obtained  excellent  results  with  instillations  of  corrosive 
sublimate.  These  may  be  administered  daily,  2  to  10  minims  to  a  dose, 
in  very  weak  solution.  Beginning  with  1 :  25,000,  the  strength  of  the 
solution  is  increased  as  far  and  as  rapidly  as  the  patient's  symptoms 
permit.    The  treatment  should  excite  no  sharp  reaction. 

Collin  employs  the  following: 


~^i   Pulv.  iodoform 1  gm, 

Guaiacol   5  gm, 

01.  oliv.  steril 100  2m 


to^ 


Chetwood  has  used  25  per  cent  to  100  per  cent  solutions  of  guaiacol 
valerianate  in  olive  oil,  and  3  per  cent  to  12  per  cent  watery  solutions  of 
thallin  sulphate.    Gomenol  is  well  spoken  of. 


SIMPLE  ULCER  OF  THE  BLADDER  435 

Surgical  Treatment. — If  the  agony  of  severe  tuberculous  cystitis  is 
not  relieved  by  such  measures  as  are  detailed  above,  it  may  be  instantly 
relieved  by  lumbar  nephrostomy  of  the  remaining  kidney/ 


SIMPLE  ULCER  OF  THE  BLADDER 

Ulcers  of  the  bladder  may  be  divided  into  six  groups :  the  traumatic, 
the  inflammatory,  the  tuberculous,  the  syphilitic,  the  malignant  and  the 
simple  ulcers. 

Traumatic  Ulcer. — Bladder  stone  of  any  size  is  likely  to  cause  ulcer- 
ation of  the  bladder  wall,  and  such  ulcerations  are  very  prone  to  be- 
come incrusted.  Similar  ulcerations  may  persist  for  some  time  after 
operations  upon  the  bladder,  notably  after  prostatectomy,  either  giving 
rise  to  stone  or  themselves  remaining  incrusted.  The  trauma  of  parturi- 
tion not  only  may  result  in  ulceration  of  the  bladder  wall,  but  may 
actually  cause  gangrene. 

Inflammatory  Ulcers.— These  have  already  been  described  (page 
369).     We  may  enumerate : 

1.  Ulcerations  incident  to  severe  cystitis. 

2.  Cystitis  of  the  superficial  ulcerative  type  due  to  mild  infection 
with  the  pyogenic  cocci. 

3.  Ulcers  of  the  type  described  by  Hunner  (see  below). 

4.  Incrusted  ulcers. 

Tuberculous  Ulceration.^ — These  have  been  described  as  forming 
a  part  of  tuberculous  cystitis  (see  page  432). 

Sjrphilitic  Ulcers. — Muscharinksi  ^  has  collected  the  data  of  9  cases 
of  syphilis  of  the  bladder  diagnosed  at  autopsy,  6  cases  diagnosed  by 
the  success-  of  treatment,  and  19  cases  diagnosed  by  cystoscopy.  The 
array  is  a  formidable  one,  but  the  documents  are  not  particularly  con- 
vincing. The  lesions  described  are  papular,  ulcerative,  and  neoplastic 
in  type.  They  cause  pyuria,  frequency  of  urination,  hematuria,  and 
retention  of  urine.  That  syphilis  of  the  bladder  may  exist  cannot  be 
denied,  but  it  must  be  very  rare.  The  clinicians  who  attribute  condi- 
tions seen  by  them  in  the  bladder  to  syphilis,  seem  rather  credulous. 
I  have  personally  encountered  but  one  case  in  which  a  colleague  saw 
a  syphilitic  ulcer  of  the  bladder,  and  cured  it  by  injections  of  salicylate 
of  mercury ;  thereby  checking  the  hemorrhage  which  was  the  patient's 
only  symptom.  But  the  hemorrhage  returned  after  a  few  months,  and 
this  time  a  nephrectomy  for  carcinoma  was  required  to  stop  it ! 

Carcinomatous  Ulcer. — Certain  carcinomatous  ulcerations  very 
closely  resemble  the  type  of  ulcer  that  becomes  incrusted  (p.  504). 

*Cf.  Boeckel,  Jour.  d'Urol,  Mar.  15,  1912,  i,  No.  3. 
''Zeitschr.  f.  Urol,  1912,  vi,  5. 


436  TUBERCULOSIS  OF  THE  PROSTATE 

Simple  Ulcer — Simple  ulcer  of  the  bladder  is  quite  as  doubtful  a 
clinical  entity  as  is  syphilitic  ulcer.  Among  the  more  important  con- 
tributions to  the  subject  may  be  mentioned  those  of  Hurry  Fenwick/ 
Gaudiani,^  and  Buerger.^  (See  also  p.  370).  The  lesion  described 
by  these  and  other  authors  is  apparently  the  incrusted  ulcer.  The 
lesion  has  been  compared  to  ulcer  of  the  stomach,  and  is  said  some- 
times to  cause  perforation.  Its  actual  origin  is  doubtless  inflammatory, 
and  its  gravity  due  as  much  to  the  irritation  of  the  phosphatic  incrusta- 
tion as  to  anything  else.  The  ulcer  may  be  single,  as  Hurry  Fenwick 
says  it  always  is ;  I  have  several  times  seen  multiple  ulcers,  however. 
Fenwick  thinks  they  usually  appear  in  the  region  of  the  ureter  orifice ; 
my  impression  is  that  they  rather  tend  to  cluster  round  the  urethra  and 
trigone. 

The  treatment  of  these  simple  ulcers,  like  that  of  the  inflammatory 
ulcers,  depends  upon  the  gravity  of  the  lesion.  A  slight  lesion  may 
be  cured  by  the  instillation  of  strong  chemicals  into  the  bladder. 
Buerger  has  cured  incrusted  lesions  by  excision  with  his  operative 
cystoscope.  I  have  both  succeeded  and  failed  with  this  instrument. 
I  confess  to  a  preference  for  argyrol,  carbolic  acid,  and  the  acidophilus 
bacillus  as  local  applications.  I  have  cured  an  incrusted  ulcer  in  a 
woman  by  curettage  through  the  urethra.  Suprapubic  section,  even  with 
curettage,  caviterization,  or  actual  excision  of  the  ulcer,  gives  no  guaran- 
tee of  a  cure  if  the  ulcer  is  incrusted.  One  can  hope  for  a  cure  only 
by  getting  rid  of  the  infection  with  pyogenic  cocci. 

Hunner  ^  has  called  attention  to  a  very  chronic  type  of  ulcer  of 
the  bladder  vault  of  young  women.  Cystoscopically  it  looks  superficial, 
but  it  may  involve  the  whole  thickness  of  the  bladder  wall.  The  only 
sure  cure  is  wide  excision. 


TUBERCULOSIS  OF  THE  PROSTATE 

Tuberculosis  of  the  prostate  is  the  central  point,  as  it  were,  of  gen- 
ito-urinary  tuberculosis.  Whether  or  not  the  prostate  is  the  site  of  the 
original  lesion  of  genital  tuberculosis,  it  is  through  the  prostate  that 
tuberculosis  of  the  urinary  tract  reaches  the  genitals,  and  vice  versa,  and 
it  is  through  tuberculosis  of  the  prostate  that  the  inflammation  crosses 
from  one  testicle  to  the  other. 

^British  Med.  Jour.,  1896,  i,  1133;  "Ulceration  of  the  Bladder,"  London,  1900. 

"Folia  Urol,  1910,  iv,  738. 

^Med.  Record,  April  12,  1913. 

*  Trans.  N.  E.  Branch  of  Am.  Urol.  Assn.,  1914-15,  p.  11. 


DIAGNOSIS  437 


ETIOLOGY 


Those  who  consider  tuberculosis  of  the  prostate  a  primary  lesion 
(cf.  p.  580)  find  its  chief  cause  in  chronic  gonorrheal  prostatitis. 
Sexual  excess,  calculus,  etc.,  have  been  incriminated,  and  in  some  cases 
the  disease  has  evidently  nothing  to  do  with  previous  inflammation. 
Like  other  tuberculous  manifestations,  it  is  commonest  in  the  young 
adult  of  a  tuberculous  predisposition.  I  cannot  accept  infection  in  coitu. 


PATHOLOGY 

Tuberculization  always  begins  just  beneath  the  glandular  epi- 
thelium. It  goes  through  the  ordinary  stages  of  caseation,  abscess 
formation,  and  fistulization,  or  it  may  terminate  by  cicatrization. 

Although  the  tuberculous  prostate  may  show  no  lesions  palpable  by 
rectal  touch,  the  disease  is  usually  bilateral,  rarely  or  only  for  a  brief 
space  confined  to  one  half  of  the  gland.  It  invades  every  part  of  the 
gland,  including  the  posterior  lobe. 

When  abscess  forms  it  usually  bursts  into  the  urethra.  I  have 
known  but  three  to  open  posteriorly.  The  tuberculosis  spreads  to  the 
posterior  urethra  and  bladder. 

SYMPTOMS 

The  disease  begins  in  one  of  four  ways : 

1.  It  is  secondary  to  a  chronic  posterior  urethritis,  assuming  its 
specific  characteristics  imperceptibly,  and  patient  and  surgeon  are  often 
unaware  of  the  change  until  rudely  aroused  by  some  of  the  typical  mani- 
festations of  tubercle  in  bladder  or  epididymis. 

2.  It  is  apparently  spontaneous.  The  patient  comes  complaining  of 
gleet  or  dysuria  for  which  he  fails  to  account. 

3.  It  is  a  minor  feature  of  an  epididymal  infection.  The  patient 
complains  of  the  enlarged  testicle,  and  is  not  aware  of  the  shreds  or  pus 
in  his  urine  that  testify  to  the  prostatic  inflammation. 

4.  Less  frequently  a  spontaneous  hematuria  or  a  urethrorrhagia  is 
the  first  sign  of  the  disease. 

The  prostate  may  be  tuberculous  for  many  years  and  yet  give  no 
symptom.  When  symptoms  arise  they  are  due  to  ulceration  of  the  pos- 
terior urethra  and  bladder  neck  and  are  precisely  those  of  tuberculous 
cystitis. 

DIAGNOSIS 

Until  periprostatic  suppuration  bursts,  and  leaves  a  rectal  or  peri- 
neal tuberculous  fistula,  we  have  no  pathognomonic  clinical  sign  of 


438  VESICULAR  TUBERCULOSIS 

tub&rculosis  of  the  prostate.  When  the  epididymis  or  the  bladder  is 
known  to  be  tuberculous,  and  the  prostate  found  to  be  swollen  or  nodular, 
we  conclude  properly  enough  that  it  is  the  seat  of  tuberculosis.  But 
in  the  absence  of  these  adjacent  lesions  the  prostate  itself  gives  no 
characteristic  sign  of  the  disease.  It  may  be  tuberculous  and  yet  show 
no  palpable  change ;  it  may  be  indurated  in  an  irregular  manner,  sug- 
gestive of  tuberculosis,  and  yet  not  be  tuberculous. 

The  prostate,  like  the  epididymis,  is  subject  to  acute  nongonorrheal 
infection  very  suggestive  of  tuberculosis,  from  which  indeed  it  is  usually 
distinguished  only  by  the  absence  of  the  tubercle  bacillus  and  the  spon- 
taneous cure  of  the  acute  prostatic  infection. 

PROGNOSIS  AND  TREATMENT 

Although  prostatic  tuberculosis  may  protract  the  duration  of  blad- 
der tuberculosis  after  the  removal  of  the  offending  kidney,  this  type 
of  tuberculosis,  nevertheless,  usually  gets  spontaneously  well  under 
hygienic  treatment. 

The  usual  type  associated  with  unilateral  or  bilateral  tuberculosis 
of  the  epididymis  and  seminal  vesicle  may  be  depended  upon  to  get  well 
with  epididymectomy  and  hygiene. 

Exceptionally,  however,  the  prostatic  and  vesicular  lesions  persist, 
and  cause  grave  stricture  of  the  urethra,  periurethral  abscess,  and 
persistent  tuberculous  cystitis.  Under  these  circumstances,  operation  is 
justifiable  with  the  object  of  removing  the  seminal  vesicle  and  more 
or  less  of  the  prostate.^  This  operation  is  justified  only  by  persistent 
and  intractable  lesions.  It  may  result  in  a  brilliant  success,  but  is 
rather  more  likely  to  result  in  large  tuberculous  perineal  fistula  with 
complete  incontinence  of  urine.  Sufficient  experience  has  not  accumu- 
lated to  determine  whether  in  these  desperate  cases  it  is  wiser  to  perform 
this  operation  or  ureterocolostomy. 


VESICULAR  TUBERCULOSIS 

Tuberculosis  of  the  vesicle  is  always  at  first  unilateral.  Before 
both  vesicles  are  affected  the  prostate  must  become  inflamed.  Whether 
tuberculosis  is  usually  primary  in  the  prostate  or  in  the  vesicle  is  not 
clear. 

The  lesions  of  localized  tuberculosis — tuberculization,  caseation,  and 
suppuration  terminating  in  fistula  or  atrophy — appear  first  near  the 
mouth  of  the  organ,  where  they  may  remain  localized  or  whence  they 
may  be  disseminated  throughout  its  length. 

iCf.  Keim,  J?ev.  Prat.  d'Obstet.,  1913,  xxi,  10. 


TREATMENT  439 


SYMPTOMS 


Commonly  there  are  no  symptoms  directly  referable  to  the  vesicle. 
Hemospermia,  abscess,  fistula,  increase  or  decrease  in  the  sexual  appetite 
— all  these  are  rare.  In  most  cases  there  is  simply  evidence  of  a  tuber- 
culosis of  the  prostate  or  of  the  epididymis,  and  examination  reveals  the 
condition  of  the  vesicle.  Simmonds  ^  examined  25  cases  of  tuberculous 
vesiculitis  post  mortem  and  only  6  of  these  were  found  to  be  sterile. 

DIAGNOSIS 

When  the  prostate  or  epididymis  is  known  to  be  tuberculous  and  the 
vesicle  is  found  dilated  or  nodular  it  may  be  assumed  to  be  tuberculous 
as  well. 

On  the  other  hand,  when  there  is  doubt  as  to  the  nature  of  the  pros- 
tatic inflammation  an  examination  of  the  vesicles  may  sometimes  throw 
some  light  upon  the  subject.  If  typical  hard  nodular  areas  of  tubercu- 
larization  are  encountered  they  at  once  establish  a  diagnosis.  But  more 
often  the  organ  is  merely  dilated  in  a  manner  suggestive  of  simple  in- 
flammation. If,  in  such  a  case,  the  urinary  and  physical  examinations 
fail  to  indicate  the  nature  of  the  disease,  the  latter  may  declare  itself  in 
a  characteristic  but  disagreeable  fashion  by  an  outburst  of  tuberculous 
epididymitis  directly  referable  to  the  examination  of  the  vesicle.  Hence 
the  rule :  never  massage  or  examine  a  suspected  tuberculous  vesicle  ex- 
cept with  the  lightest  possible  touch. 


TREATMENT 

All  local  treatment  of  a  palliative  sort  must  be  studiously  avoided. 
Massage  and  douching  do  not  benefit  the  vesicle,  but  endanger  the  tes- 
ticle. Here,  as  elsewhere,  the  general  hygienic  treatment  of  tuberculosis 
is  of  prime  importance. 

Surgical  Treatment — Inasmuch  as  tuberculosis  of  the  seminal  vesi- 
cle and  prostate  is  unquestionably  kept  active  by  the  presence  of  tuber- 
culosis in  the  epididymis,  there  can  be  no  question  of  the  advisability 
of  removing  the  epididymal  focus  as  soon  as  the  diagnosis  is  certain. 

On  the  other  hand,  it  is  quite  obviously  absurd  to  expect  to  ampu- 
tate tuberculosis  of  the  epididymis  or  of  the  testicle,  and  thus  to  get  rid 
of  all  the  tuberculosis  in  the  body.  In  fully  half  of  the  cases  the 
opposite  testicle  will  become  involved  no  matter  what  operation  is  per- 
formed, unless  the  patient  submits  to  prolonged  treatment  by  hygiene 
and  tuberculin  after  the  operation. 

^Deutsch.  ArcMv  /.  Min.  Med.,  1898,  Ixi,  412. 


440  VESICULAR  TUBERCULOSIS 

In  a  number  of  patients  I  have  examined  the  semen  before  opera- 
tion, found  it  sterile,  and  at  the  time  of  removing  a  single  epididymis 
I  have  divided  the  opposite  vas.  Xone  of  these  patients  has,  so  far 
as  I  know,  had  an  infection  of  the  opposite  epididj-mis.  This  is  a 
prophylactic  measure  worthy  of  consideration. 

Vesiculectomy  for  tuberculosis  gives  most  discouraging  resultSo 


# 


QHAPTEB  XLV 
MOVABLE  KIDNEY 

The  kidney  is  naturally  endowed  with  a  certain  degree  of  mobility. 
Like  the  other  abdominal  viscera  it  moves  with  respiration  and  its  posi- 
tion is  influenced  by  the  attitude  of  the  subject.  Yet  this  condition  is 
etitirely  nonnal.  Such  a  kidney  is  not  distinctly  palpable.  A  movable 
kidney,  on  the  other  hand,  is  one  that  is  subject  to  downward  displace- 
ment to  such  an  extent  that  it  may  be  distinctly  palpated  by  the  usual 
methods  of  examination.  Continental  writers  distinguish  mobility  of 
the  first  degree  (the  fingers  can  grasp  the  kidney),  the  second  degree 
(the  fingers  can  be  brought  together  above  the  organ),  and  the  third 
degree  (the  kidney  can  be  depressed  into  the  iliac  fossa)  = 


FREQUENCY 

The  recorded  frequency  of  movable  kidney  varies  with  the  point  of 
v^iew  of  the  author  and  the  delicacy  of  his  sense  of  touch.  The  widely 
divergent  opinions  of  various  writers  may  be  tabulated  thus : 


Women. 

Per  Cent. 

M] 

2N. 

Cases 
Examined. 

Movable 
Kidney. 

Cases 
Examined. 

Movable 
Kidney. 

Per  Cent. 

Bergmann ' 

905 
543 
832 
306 
603 
100 
126 

40 
112 
240 

85 
212 

42 

71 

4.41 
20 

28 
25 
35 

42 
56 

828 

772 

1,080 

268 
100 

4 
14 

42 

6 
6 

0.48 

Einhorn  ^ 

1.81 

Idem  * 

Mathieu  * 

3.88 

Godard-Danhieux  ^. . .  . 
Suckling  ® 

2.33 
6 

Harris' 

*  Op.  cit.,  p.  134. 

==  Med.  Becord,  1898,  }iv,  220. 

"Ibid.,  1901,  lix,  561. 

*Le  bull  med.,  1893,  vii,  1113. 

'Guyon's  Annales,  1901,  xix,  197. 

'Edinb.  Med.  Jour.,  1898,  iv,  228. 

''Jour,  of  the  Am.  Med.  Assn.,   1901,  xxxvi,  1527. 

441 


442  MOVABLE  KIDNEY 

Many  of  these  statistics  are  obviously  compiled  in  camera,  and  repre- 
sent only  the  physician's  interpretation  of  the  term  "movable  kidney" 
vi'ithout  any  reference  to  the  patient's  symptoms.  The  average  observer 
will  probably  recognize  a  movable  kidney  in  20  per  cent  of  v^omen  and  2 
per  cent  of  men ;  yet  the  cases  which  have  symptoms  and  require  treat- 
ment are  far  fewer  than  this. 

There  is  a  general  agreement  that  in  8  cases  out  of  10  the  right  kid- 
ney only  is  movable;  of  the  remainder  the  majority  are  bilateral,  uni- 
lateral left-sided  nephroptosis  being  most  unusual.  When  both  kidneys 
are  movable,  the  right  kidney  is  usually  more  movable  than  the  left. 

Although  movable  kidneys  have  been  discovered  in  patients  of  all 
ages,  the  symptoms  of  the  disease  appear  in  the  third  decade  of  life  and 
disappear  between  the  fortieth  and  fiftieth  years. 


PATHOGENESIS 

To  be  satisfactory,  a  theory  must  explain  (a)  the  predominance  of 

movable  kidney  in  woman,  (6)  the  frequency  with  which  it  occurs  on 

the  right  side,  and  (c)  its  importance  between  the  ages  of  twenty  and 

forty. 

We  shall  consider : 

a.  Causes  of  congenital  nephroptosis. 

h.  Causes  of  acquired  nephroptosis. 

Primary  predisposing  cause. — Shape  of  the  lumbar  recess. 

fEnteroptosis. 

Secondary  predisposing  cause-^  Pregnancy. 

[Emaciation. 

-r^     •^-  f  Corsets. 

Exciting  causes  <  ^ 

°  1^  Irauma. 

a.  Causes  of  Congenital  Nephroptosis. — The  existence  of  congenital 
nephroptosis  has  been  doubted,  but  the  possibility  of  such  a  condi- 
tion is  proved  by  such  cases  as  Dr.  W.  E.  Stewart's.  In  this  case  an 
exploratory  operation  performed  for  intestinal  obstruction  on  an  infant 
eight  months  old  disclosed  a  floating  kidney.  Abt  -^  and  Morris  have 
collected  similar  cases.  Yet  the  discovery  of  a  movable  kidney  in  a  child 
is  undoubtedly  exceptional,  and  the  occurrence  of  any  symptoms  before 
puberty  is  rarer  still. 

With  our  present  knowledge  it  is  impossible  to  say  what  may  be  the 
cause  of  this  condition.  It  has  not  been  determined  how  far  the  factors 
that  operate  in  later  life  are  at  work,  and  how  great  a  part  actual  ab- 
normal development  plays.     Coffey,"  however,  states  that  "a  unilateral 

^  Jour,  of  the  Am.  Med.  Assn.,  1901,  xxxvi,  1166. 
'Surg.,  Gynec.  and  Ohstet.,  1912,  xv,  381. 


PATHOGENESIS  443 

right  movable  kidney  is  almost  never  seen  except  in  cases  where  there 
has  been  a  deficient  peritoneal  fusion  of  the  ascending  colon  and  meso- 
colon with  the  parietal  peritoneum  in  front  of  the  kidney." 

h.  Causes  of  Acquired  Nephroptosis. — Primary  Predisposing 
Cause. — Wolkow  and  Delitzen  ^  have  shown  by  an  extensive  series  of 
pathological  investigations  that  there  is  quite  a  wide  variation  in  the 
size  of  the  niche  in  the  loin  occupied  by  the  kidney.  The  paravertebral 
niche,  as  they  call  it,  is  shallower  in  women  than  in  men,  shallower  on 
the  right  side  ^  than  on  the  left.  The  feminine  peculiarity  appears  with 
the  broadening  of  the  pelvis  at  the  advent  of  puberty;  and  it  is  this 
feminine,  right-sided  shallowness  of  the  bed  in  which  the  kidney  lies 
that  is  the  chief  predisposing  cause  of  nephroptosis.  Harris  has  gone 
even  further,  and  maintains  that  the  chief  characteristics  of  the  body 
form  that  predispose  to  nephroptosis  "are  a  marked  contraction  of  the 
middle  zone  of  the  body  with  a  diminution  in  the  capacity  of  this  por- 
tion of  the  body  cavity.  This  diminution  in  the  capacity  of  the  middle 
zone  depresses  the  kidney,  so  that  the  constricted  outlet  of  the  zone 
comes  above  the  center  of  the  organ,  and  all  acts,  such  as  coughing, 
straining,  lifting,  flexions  of  the  body,  etc.,  which  tend  to  adduct  the 
lower  ribs,  press  on  the  upper  pole  of  the  kidney  and  crowd  it  still 
farther  downward.  It  is  the  long-continued  repetition,  in  a  suitable 
body  form,  of  these  influences,  which  collectively  may  be  called  internal 
traumata,  that  gradually  produces  a  movable  kidney." 

Secondary  Predisposing  Causes. — The  internal  traumata  just 
mentioned,  and  many  others,  such  as  intermittent  renal  congestion  dur- 
ing menstruation,  prolapse,  and  inflammation  of  the  pelvic  organs,  etc., 
may  be  included  here ;  but  we  need  discuss  only  four  alleged  causes — 
viz.,  enteroptosis,  weakness  of  the  abdominal  wall,  pregnancy,  and  ema- 
ciation. 

Enteroptosis  is  a  general  condition,  of  which  nephroptosis  is  often 
one  of  the  features.  Glenard  ^  considers  that  nephroptosis  never  exists 
without  a  general  enteroptosis,  but  he  stands  alone  in  this  opinion.  Ein- 
horn  ^  has  seen  27  cases  of  enteroptosis  without  nephroptosis,  and  213 
cases  in  which  both  conditions  existed;  hepatoptosis  occurred  with 
nephroptosis  only  30  times,  54  times  without  it;  while  in  57  cases  only 
the  kidney  was  movable.  Similarly  Godard-Danhieux  ^  records  131 
cases  of  nephroptosis  without  enteroptosis,  and  81  cases  with  it;  while 
in  97  instances  there  was  enteroptosis  without  nephroptosis. 

Modern  radiography  has,  however,   shown  coloptosis  to  be  much 


1 1 1 


Die  Wanderniere, "   1899,   Berlin. 
2  Chiefly  because  the  liver  fills  tlie  upper  segment  of  the  niciie  on  this  side. 
'"Les  Ptoses  viscerales,"  Paris,  1899.     Lyo7i  mecl.,  1885,  xliv,  8. 
*Med.  Hecord,  1898,  liv,  220;  1899,  Ivi,  397;  and  1901,  lix,  561. 
« Gas.  hebd.,  1900,  v,  159. 


444  MOVABLE  KIDNEY 

more  common  than  had  been  supposed,  and  the  tendency  is  once  again 
to  attach  nephroptosis  to  general  enteroptosis  hy  means  of  the  nephro- 
colic  ligament,  a  band  leading  from  the  hepatic  flexure  to  the  lower  pole 
of  the  right  kidney/ 

Pregnancy  introduces  another  dispute.  It  is  an  accepted  fact  that 
repeated  pregTiancies  favor  relaxation  of  the  abdominal  wall  and  en- 
teroptosis, yet  there  is  an  absolute  disagreement  in  the  statistics  on 
nephroptosis.  Landau,  Senator,  Moulin,  Morris,  and  others  maintain 
that  movable  kidney  is  more  frequent  in  women  who  have  borne  chil- 
dren, while  Kiittner,  Godard-Danhieux,  and  Lindner  defend  the  op- 
posite theory. 

Weakness  of  the  ahdominal  wall,  Wolkow  and  Delitzen  insist,  is  a 
strong  predisposing  factor  in  enteroptosis  and  nephroptosis.  The  ab- 
dominal viscera  are  deprived  of  their  necessary  support,  and  therefore 
sag  downward,  carrying  the  kidneys  with  them,  in  case  the  shallowness 
of  the  paravertebral  niches  makes  these  organs  liable  to  prolapse. 

Emaciation,  it  is  stated,  causes  nephroptosis  by  absorption  of  the 
perirenal  fat.  Morris  has  often  noted  the  small  quantity  of  fat  that  sur- 
rounds kidneys  requiring  nephrorrhaphy.  Yet  one  can  scarcely  believe 
that  the  absorption  of  fat  could  be  so  sudden  as  to  leave  a  space  into 
which  the  kidney  would  sag.  On  the  other  hand,  it  is  quite  conceivable 
that  the  excursions  of  a  movable  kidney  should  discourage  the  deposition 
of  fat  within  its  fascial  envelope. 

Exciting  Causes. — Corsets  have  been  alternately  praised  and  con- 
demned. A  corset  that  brings  pressure  to  bear  below  the  kidney  region 
will,  if  applied  while  the  kidney  is  in  place,  help  to  retain  a  movable 
organ;  while  a  long-waisted  corset  that  compresses  the  ribs  is  equally 
likely  to  encourage  renal  mobility.  The  fact  that  Egyptians  suffer  from 
movable  kidney  is  evidence  that  the  corset  does  not  deserve  all  the  blame 
which  has  been  heaped  upon  it.  Yet  it  does  weaken  the  abdominal  wall 
and  so  increases  the  liability  to  nephroptosis. 

Position  is  justly  blamed  by  Cabot  and  Browne,  who  maintain  that 
the  drooping,  flat-chested,  round-shouldered  attitude  compresses  the 
lower  ribs  and  is  the  occasion  of  many  cases  of  renal  mobility. 

Trauma  of  one  sort  or  another  is  certainly  the  exciting  cause  of  all 
cases  of  movable  kidney.  But  it  is  equally  certain  that  the  trauma  in 
question  is  usually  of  a  mild  type.  Suckling  mentions  the  influence  of 
constant  stooping.  The  internal  traumata  recognized  by  Harris  have 
been  enumerated.  The  influence  of  pregTiancy  and  corsets  has  already 
been  mentioned.  Bergmann  insists  upon  the  evil  effect  of  horseback 
riding. 

The  effect  of  acute  trauma,  such  as  falls,  kicks,  and  blows,  is  an  open 
question.    Harris  absolutely  denies  its  influence,  and  though  many  acute 

*Cf.  Longyear,  "  Nephroeoloptosis, "   1910. 


SYMPTOMS  445 

cases  from  this  cause  have  been  enumerated,  I  believe  that  in  most  in- 
stances the  trauma  has  been  only  the  cause  of  symptoms  in  an  organ 
alread}^  movable. 

Secondary  Changes. — As  a  result  of  long-continued  mobility  the 
renal  vessels  may  become  considerably  lengihened.  They  are  the  radii 
of  the  circle  in  which  the  kidney  moves;  as  they  lengthen  mobility  in- 
creases. 

The  ureter  may  become  kinked,  and  in  this  event,  which  is  by  no 
means  uncommon,  the  free  outflow  of  urine  is  obstructed,  renal  colic 
ensues,  and  the  kidney  becomes  inflamed  or  hydronephrotic. 

Adhesions  may  form  as  a  result  of  repeated  attacks  of  hydronephro- 
sis or  of  other  inflammation  of  the  kidney  itself  or  of  surrounding 
tissues.     Such  adhesions  increase  the  ureteral  obstruction. 

The  kidney  itself  may  be  misshapen  through  pressure,  or  inflamed 
or  hydronephrotic. 

Exceptionally  gangrene  of  the  kidney  has  occurred  from  torsion  of 
the  pedicle. 

SYMPTOMS 

So  as  to  bring  order  out  of  the  contradictory  opinions  concerning 
the  symptoms  of  movable  kidney,  we  may  take  as  the  basis  of  our  de- 
scription a  few  commonly  accepted  facts.  In  the  first  place,  any 
surgeon  familiar  with  abdominal  palpation  appreciates  that,  in  examin- 
ing a  patient,  one  occasionally  flnds  a  movable  kidney  which  has  never 
given  any  symptoms,  and  of  whose  existence  the  patient  will  not  become 
aware  unless  the  surgeon  announces  his  discovery.  A  second  class  of 
cases,  while  having  a  movable  kidney  and  suffering  from  various  symp- 
toms— digestive,  neurotic,  or  pelvic — ^have  no  symptoms  directly  refer- 
able to  the  kidney  itself.  The  organ  is  neither  tender,  adherent,  nor 
enlarged.  There  is  no  history  of  hydronephrosis,  no  evidence  of  either 
urinary  infection  or  renal  sclerosis.  Finally,  there  are  other  cases 
with  symptoms  directly  referable  to  the  kidney  itself.  Thus  nephrop- 
tosis is  encountered  clinically  under  three  aspects : 

1.  ]!*^ephroptosis  without  symptoms. 

2.  Nephroptosis  without  symptoms  directly  referable  to  the  kidney. 

3.  Nephroptosis  with  symptoms  directly  referable  to  the  kidney. 
Nephroptosis  without  Symptoms  Directly  Referable  to  the  Kidney. 

— The  gi'eater  number  of  cases  commonly  classed  as  movable  kidney 
come  under  this  head,  and  it  is  the  infinite  variety  of  symptoms  which 
such  cases  present,  the  doubtful  origin  of  these  symptoms,  and  the 
uncertainty  of  their  cure,  that  has  obscured  the  whole  subject  and 
given  rise  to  opinions  so  divergent  and  to  discussion  so  virulent. 

The  class  of  cases  under  discussion  has  but  two  common  features: 


446  MOVABLE  KIDNEY 

(1)  The  subjective  symptoms  are  referable  to  any  one  of  several  diseases 
of  organs  other  than  the  kidneys,  and  (2)  one  or  both  kidneys  are  mov- 
able, but  present  no  signs,  either  subjective  (pain)  or  objective,  of  dis- 
ease. Such  patients  may  present  nervous  symptoms,  digestive  disorders, 
or  painful  symptoms.  These  symptoms  are  exhibited  in  greater  or  less 
degree  and  in  various  combinations. 

Nekvous  Symptoms. — It  is  quite  impracticable  to  detail  here  the 
various  symptoms  of  neurasthenia  with  abdominal  manifestations  that 
have  been  attributed  to  renal  mobility.  Their  name  is  legion.  But 
the  question  tha,t  always  arises  is :  Does  the  neurasthenia  depend  upon 
the  movable  kidney  ?  Two  answers  may  be  suggested.  If  temporary 
reposition  of  the  affected  organ  by  dorsal  decubitus  brings  temporary 
relief  from  the  symptoms,  and  if  with  renewal  of  the  kidney  prolapse 
the  sjTuptoms  recur,  there  is,  clinically  speaking,  an  established  connec- 
tion between  the  mobility  of  the  kidney  and  the  nervous  symptoms. 
In  the  second  place,  it  may  be  found  that  there  is  nephritis  or  renal  in- 
fection. In  this  case  the  nervous  symptoms  may  possibly  be  attributed 
to  renal  autointoxication. 

Digestive  Disoedeks. — The  flatulent  dyspepsia  and  constipation 
that  figure  so  prominently  among  the  symptoms  of  nephroptosis  are  but 
rarely  referable  to  the  kidney.  Einhorn's  opinion  upon  this  subject  de- 
serves quotation: 

Most  of  the  gastric  and  intestinal  symptoms,  such  as  pains,  eructations, 
nausea,  occasional  vomiting,  irregularity  of  the  bowels  (chiefly  constipation, 
somethimes  diarrhea),  which  are  present  in  persons  with  movable  kidney, 
occur  usually  independently  of  the  latter,  and  require  therapeutic  measures 
appropriate  to  such  conditions. 

Here,  again,  the  tests  applied  to  neurotic  cases  are  of  service.  If 
lying  down  relieves  the  symptoms,  or  if  there  is  renal  insufficiency, 
some  connection  between  the  renal  condition  and  the  digestive  disturb- 
ance may  be  suspected. 

We  may  mention  here  the  theory  originated  by  Edebohls  ^  that 
movable  kidney  on  the  right  side  may  cause  chronic  appendicitis  by 
pressure  upon  the  superior  mesenteric  vein. 

Painful  Symptoms. — The  pains  most  often  caused  by  movable 
kidney  are:  (1)  Pain  and  tenderness  in  the  kidney  itself;  (2)  pain 
of  a  dull,  dragging  character  low  down  in  the  back,  a  pain  comparable 
to  that  commonly  attributed  to  uterine  retrodisplacement ;  (3)  fre- 
quent and  painful  urination.  It  is  characteristic  that  these  pains 
should  be  increased  by  exercise,  and  should  be  more  severe  during  the 
menstrual  period.  Any  of  them  may  be  attributable  to  conditions 
other  than  nephroptosis.     Therefore  it  is  essential  that  they  should  be 

^  Post-Graduate,  IS^O,  xiv.   85. 


DIAGNOSIS  447 

known  to  disappear  with  reposition  of  the  kidney,  and  to  reappear 
with  its  prolapse  before  we  can  be  sure  of  any  connection  between  the 
pain  and  the  renal  mobility. 

Nephroptosis  with  Symptoms  Directly  Referable  to  the  Kidney - 

Here  we  enter  upon  a  more  definite  field  of  investigation.  If  the 
kidney  is  tender  and  painful,  if  the  tenderness  is  relieved  by  reposition 
of  the  organ,  if  there  is  renal  colic,  or  if  the  tender  kidney  is  enlarged 


Fig.  97. — Movable   Kidney   Injected   with  Argyrol.      Patient  had  hud  a  Dietl  crisis. 
Injection  shows  absence  of  hydronephrosis. 

or  adherent  in  an  abnormal  position,  we  have  direct  physical  evidence 
that  the  symptom  is  due  to  the  nephroptosis.  Even  more  characteristic 
is  the  intermittent  hydronephrosis  (cf.  p.  460)  due  to  movable  kidney. 
It  is  usually  very  painful,  and  its  growth  is  often  attended  by  renal  colic 
(Dietl's  crisis),  rarely  by  profuse  hematuria. 

Renal  infection  may  also  complicate  mobility. 

Lillienthal  ^  has  reported  two  cases  which  he  interprets  as  torsion 
of  the  kidney. 

DIAGNOSIS 

If  the  kidney  is  only  slightly  movable  this  may  be  dotected  by  bal- 
lottement.    A  floating  organ  may  be  discovered  almost  anywhere  in  the 
*Am.  Jour,  of  Dermatol.,  3912,  xvi,  No.  5. 


448  MOVABLE  KIDNEY 

abdomen.  As  a  rule,  it  is  not  difficult  to  distinguisH  a  floating  kidney 
from  other  abdominal  tumors.  The  very  mobility  of  the  organ,  the 
fact  that  it  may  be  replaced  in  the  loin,  together  with  its  general  con- 
tour, and  the  sickening  sensation,  similar  to  and  yet  not  the  same  as 
the  ovarian  sensation,  caused  by  pressure  upon  it,  are  sufficiently  char- 
acteristic. Tumors  arising  from  the  ovaries  or  uterus  may  be  distin- 
guished by  their  pelvic  attachments.  To  distinguish  a  movable  kidney 
from  a  distended  gall-bladder,  or  a  corset-lobe  of  the  liver,  we  sometimes 
have  to  resort  to  pyelography. 

But  the  discovery  of  a  movable  kidney  by  no  means  completes  the 
diagnosis.  It  is  equally  important  to  ascertain  whether  the  symptoms 
are  due  to  the  nephroptosis  or  to  something  else.  In  some  cases  there 
can  be  no  doubt  that  the  kidney  is  at  fault.  If  a  hydronephrosis,  a  pyo- 
nephrosis, or  an  adherent  organ  is  discovered,  here  is  a  pathological  con- 
dition demanding  treatment.  Then  there  are  the  tender  kidneys  and 
those  cases  whose  symptoms  are  temporarily  relieved  by  rest  and  reposi- 
tion of  the  displaced  organ.  These  form  a  doubtful  class,  and  merit  the 
most  minute  examination  and  the  closest  watching,  of  which  the  palli- 
ative treatment  of  the  disease  forms  an  important  part.  The  majority 
of  them  are  complicated  by  some  neurotic  tendency,  enteroptosis,  or 
gastro-intestinal  or  pelvic  disease.  Their  judicious  treatment  is  pecul- 
iarly difficult.  Finally,  there  are  the  cases  in  which  no  test  can  show 
a  direct  connection  between  the  renal  ptosis  and  the  symptoms. 


TREATMENT  i 

In  deciding  upon  the  proper  course  of  treatment  for  any  individual 
case  of  movable  kidney,  the  surgeon  must  bear  in  mind  the  following 
facts : 

1.  In  many  cases  nephroptosis  produces  no  symptoms. 

2.  In  many  instances  nephropexy,  while  it  retains  the  kidney  in 
place  (which  it  does  not  always  do),  either  fails  to  relieve  or  aggravates 
the  neurotic  or  dyspeptic  symptoms  attributed  to  renal  mobility. 

In  view  of  these  facts  we  must  hesitate  to  elect  nephropexy,  a  treat- 
ment which,  though  surgically  a  success,  may  prove  clinically  a  failure, 
or  worse  than  a  failure.  Mechanical  treatment — supporting  the  kidney 
by  a  suitable  belt — may  always  be  experimentally  employed  in  doubtful 
cases.  But  to  have  recourse  to  surgery  is  a  gxave  matter.  IsTot  because 
of  the  danger  or  discomfort  connected  with  the  operation,  for  the  for- 
mer is  almost  nil,  the  latter  inconsiderable,  but  because  in  most  instances 
the  patient  is  distinctly  neurotic,  and,  while  the  influence  of  the  opera- 

^  An  exhaustive  review  has  been  published  by  Scheuermann  (ArcMv  f.  Tclin.  Chir., 
1914,  civ,  No.  1). 


TREATMENT  449 

tion  per  se  may  be  beneficial,  it  may  also  be  injurious.  In  short,  the 
knife  is  no  proper  instrument  for  a  faith  cure.  Its  brilliant  successes 
should  not  blind  us  to  its  failures.  Yet  where  palliative  measures  fail, 
and  the  symptoms  are  apparently  dependent  upon  the  renal  mobility 
and  require  relief,  there  is  no  choice.  An  operation  is  then  surely  the 
lesser  evil.  So  we  may  conclude  that  the  treatment  of  subjective  symp- 
toms due  to  renal  mohility  is  palliative;  surgical  measures  should  he 
reserved  for  the  treatment  of  kidneys  showing  definite  pathological 
lesions,  and  for  those  cases  that  do  not  respond  to  persistent,  intelligent 
palliative  treatment. 

Palliative  Treatment. — The  broad  lines  of  palliative  treatment  are 
the  following: 

1.  To  remedy  digestive  and  menstrual  derangements. 

2.  To  correct  position  and  avoid  overfatigue. 

3.  To  improve  the  general  vitality  and  combat  neurasthenia  by  over- 
feeding, massage,  hygiene,  and  tonics,  and 

4.  To  apply  an  abdominal  supporter. 

Much  emphasis  is  placed  upon  the  kind  of  belt  or  corset  employed 
to  support  the  abdomen.  Edebohls  ^  reviews  the  opinions  of  various 
writers  upon  this  subject,  even  to  that  of  Gurtzburg,  who  "administers 
a  yeast  fennent  with  the  object  of  producing  meteorism,  and  thus  sus- 
taining the  prolapsed  kidney,"  This  is  an  extreme  example  of  the  fal- 
lacious impression  that  a  support  must  be  worn  solely  for  the  purposes 
of  retaining  a  kidney  in  place,  and  that,  this  accomplished,  the  cure  is 
assured.  ISTothing  could  be  further  from  the  truth.  As  a  matter  of  fact, 
it  is  the  patient's  general  condition  that  should  be  attacked  primarily, 
the  local  condition  only  secondarily.  Many  a  case  of  "movable  kidney" 
is  cured  by  hygiene,  diet,  and  exercise,  while  the  kidney  remains  as  loose 
as  ever.  Moreover,  in  applying  a  belt  or  a  corset  the  effort  must  be  made 
to  support  all  the  abdominal  viscera,  not  the  kidney  only.  It  is  not 
conceivable  that  any  form  of  pad  should  hold  the  kidney  in  place,  and 
therefore  it  is  wiser  to  dispense  entirely  with  pads  and  to  support  the 
abdominal  contents  en  masse.  For  this  purpose  the  modern  straight- 
front  corset  may  be  employed.  Some  women  find  that  this,  if  applied 
in  the  recumbent  position,  acts  as  an  admirable  supporter. 

The  backbone  of  the  non-operative  prevention  and  cure  of  the  symp- 
toms of  nephroptosis  is  a  course  of  orthopedic  training  in  proper  posi- 
tion. The  patient  must  learn  to  stand  and  walk  touching  the  clouds 
with  the  crown.  "Chest  out,  and  everything  else — chin,  abdomen,  lips, 
toes — in,"  must  be  the  rule.  Such  an  attitude  makes  room  for  the  solid 
viscera  under  the  diaphragm  and  relieves  many  patients. 

Surgical  Treatment — Nephropexy  (nephrorrhaphy)  is  the  opera- 
tion of  fixing  the  prohipsed  kidney  against  the  abdomiiuil  wall. 

"■Med.  Record,  1901,  lix,  690. 


450  MOVABLE  KIDNEY 

Results  of  I^ephkopexy.^ — The  earlier  nephropexies  were  so  uni- 
formly followed  by  relapse  that  many  physicians  opposed  the  operation 
on  the  ground  that  a  permanent  cure  was  never  accomplished  by  opera- 
tion; but  recent  statistics  tell  an  entirely  different  story.  Morris  has 
performed  98  nephropexies  with  1  death  (''cardiac  thrombosis  in  a  stout 
female  whose  kidney  was  incised  and  explored  before  being  fixed"), 
and  only  "a  few"  relapses  after  operations  performed  according  to  "a. 
plan  different  from  the  present  methods."  Edebohls  reports  193  cases 
(68  bilateral),  with  3  deaths  and  2  known  relapses.  All  of  my  own 
cases  have  been  successful. 

But  nephropexy  may  be  regarded  from  another  point  of  view.  In  a 
very  considerable  proportion  of  cases  the  patients  have  complained  of 
more  pain  after  the  operation  than  before.  This  may  be  due  to  one  of 
several  factors :  perhaps  the  pain  did  not  commence  in  the  kidney,  and 
therefore  was  not  relieved  by  operation,  but  was  rather  intensified  by 
the  shock  and  disappointment;  or  perhaps  it  was  due  to  adhesions  or 
kinks  of  the  ureter  which  were  not  relieved  by  the  surgeon;  or  per- 
haps the  kidney  was  replaced  high  up  in  the  loin  in  a  niche  from  which 
it  had  descended  because  there  was  not  sufficient  room  for  it  (Harris). 
However  this  may  be,  I  have  had  only  one  patient  complain  of  a  recur- 
rence of  pain.  ISTephropexy  was  performed  upon  her  as  a  lesser  evil  than 
exploratory  abdominal  section,  with  which  she  was  threatened  by  an- 
other surgeon.  Her  various  neurotic  symptoms,  which  had  existed  for 
years,  immediately  disappeared.  Five  years  later  they  returned,  and 
she  underwent  at  the  hands  of  various  surgeons  the  extraction  of  several 
teeth,  drainage  of  the  antrum  of  Highmore,  excision  of  the  inferior 
dental  nerve,  nephrectomy  (the  kidney  was  found  firmly  adherent), 
vesicovaginal  fistulization,  an  infinite  variety  of  other  treatments,  all 
to  no  avail.  It  has  been  interesting  to  find  two  reports  of  her  cure,  the 
one  by  a  dentist,  the  other  by  a  physician  who  inflated  her  colon  with 
carbonic  acid  gas.  Finally,  exploratory  laparotomy  was  performed  a 
year  ago.  A  normal  appendix  was  removed — and  she  has  remained 
better  ever  since,  though  far  from  well.  She  has  been  poisoned  by  a 
rectal  injection  of  boric  acid,  but  survived  ! 

^Cf.  Scheuermann,  Archiv  f.  klin.  Chir.,  1914,  civ,  No.  1. 


CHAPTER   XLVI 
THE  URETERS  AND  THEIR  DISEASES 

ANATOMY 

The  ureter  is  the  excretory  duct  of  the  kidney.  It  is  a  iibromus- 
cular  tube  beginning  at  the  funnel-shaped  neck  of  the  renal  pelvis  and 
terminating  at  the  lateral  angle  of  the  trigone  of  the  bladder.  There  is 
normally  one  ureter  for  each  kidney.  Each  ureter  is  from  25  to  30  cm. 
long.  The  ureter  is,  when  empty,  a  closed  tube  like  the  urethra.  Its 
physiological  caliber  is  that  of  a  cylinder  about  0.3  cm.  {-g  inch)  in 
diameter.  The  lumen  of  the  ureter  is  slightly  constricted  at  four  points : 
(1)  A  distinct  narrowing  at  a  point  about  2  cm.  from  its  upper  extrem- 
ity, (2)  a  slight  narrowing  where  it  crosses  the  brim  of  the  pelvis,  (3) 
a  muscular  constriction  at  its  entrance  into  the  bladder  wall,  and  (4)  at 
the  vesical  orifice. 

Structure. — The  ureter  is  composed  of  three  coats :  the  fibrous,  the 
muscular,  and  the  mucous. 

The  fibrous  external  coat  runs  continuously  from  the  fibrous  en- 
velope of  the  kidney  and  its  pelvis  to  the  bladder.  It  is  a  tough, 
glistening,  elastic  tissue. 

The  muscular  coat  consists  of  an  external  longitudinal  and  an  in- 
ternal circular  layer  of  smooth  muscle.  It  is  well  developed  in  both  the 
ureter  and  the  pelvis  of  the  kidney.  In  the  calices  it  thins  out  to  a  few 
stray  fibers.  At  the  vesical  extremity  of  the  ureter  its  muscle  pierces 
that  of  the  bladder  and  is  continued  as  a  band  of  fibers  running  along- 
each  edge  of  the  trigone.  Thus  there  is  one  band  joining  the  two  ureters 
(interureteric  muscle)  which  sometimes  raises  a  distinct  transverse  fold 
in  the  mucous  membrane,  while  another  thinner  band  of  fibers  runs  from 
each  ureter  toward  the  neck  of  the  bladder.  The  ureter  possesses  no 
proper  sphincter.  Its  power  of  resisting  regurgitation  from  the  bladder 
is  due  to  its  oblique  course  through  the  muscular  wall  of  the  bladder, 
and  to  the  constriction  of  the  bladder  muscle,  which  automatically 
closes  the  ureteral  orifices  as  it  contracts  to  force  the  urine  into  the 
urethra. 

The  mucous  membrane  of  the  ureter  is  smooth  and  thrown  into  longi- 
tudinal folds  when  the  organ  is  collapsed.     The  epithelium  consists  of 

451 


452  THE  URETERS  AND  THEIR  DISEASES 

several  superposed  layers,  the  deeper  ones  conical  or  ovoidal,  tlie  super- 
ficial ones  cuboidal  or  flattened.  Though  some  expert  microscopists 
claim  to  be  able  to  distinguish  the  epithelium  of  the  pelvis  of  the  kidney 
from  that  of  the  ureter,  most  conservative  observers  confess  their  inabil- 
ity to  make  such  a  distinction,  and  do  not  even  venture  to  assert  that 
any  given  cells  in  the  urine  come  from  any  part  of  the  ureter  or  its 
pelvis  unless  the  presumption  is  confirmed  by  other  signs,  notably  the 
presence  of  renal  casts  and  albumin. 

Relations. — The  ureter  lies  immediately  behind  the  peritoneum 
throughout  almost  its  whole  length.  It  is  firmly  attached  to  this  struc- 
ture, so  that  when  the  peritoneum  is  detached  from  the  parietes  the 
ureter  is  carried  with  it.  When  this  dissection  is  performed  by  the 
finger  the  ureter  may  be  identified  as  a  cord  interrupting  the  smooth 
yielding  surface  of  the  peritoneum  within  3  cm.  (1^  inches)  of  the 
spinal  column.  In  the  abdomen  the  ureter  lies  upon  the  psoas  muscle 
and  crosses  the  genitocrural  nerve.  It  is  in  turn  crossed  by  the  sper- 
matic (or  ovarian)  vessels.  On  the  right  side  it  lies  close  to  the  vena 
cava.  At  the  brim  of  the  pelvis  it  crosses  the  common  iliac  vessels  at 
or  near  their  bifurcation.  Thence  it  plunges  down  in  a  fold  of  peri- 
toneum (posterior  false  ligament  of  the  bladder),  passes  under  the  arch 
of  the  vas  deferens,  external  to  it,  entering  the  bladder  wall  close  above 
the  seminal  vesicle  and  about  2  cm.  from  the  median  line.  Thence  it 
runs  2  cm.  obliquely  forward  and  inward  through  the  bladder  muscle 
and  beneath  the  mucous  membrane,  and  emerges  at  the  angle  of  the 
trigone  3  cm.  from  its  fellow  and  the  same  distance  from  the  urethral 
orifice. 

Topographical  Anatomy. — The  ureter,  like  the  appendix,  cannot  be 
felt  when  normal.  When  tender  or  enlarged,  however,  in  a  thin  subject 
it  may  be  traced  almost  from  the  kidney  to  the  brim  of  the  pelvis.  In 
fieshy  subjects  it  can  only  be  felt  at  this  latter  point— viz.,  at  the  outer 
edge  of  the  rectus  muscle  on  a  line  joining  the  anterior  spines  of  the  ilia. 
In  the  female  pelvis  the  diseased  ureter  is  felt  through  the  vaginal  vault 
almost  up  to  the  pelvic  brim.  But  in  the  male  it  is  only  in  exceptional 
cases  that  tenderness  or  enlargement  at  the  lower  extremity  of  the 
ureter  can  be  appreciated  by  rectal  touch  in  the  region  just  internal 
to  the  base  of  the  seminal  vesicle. 


PHYSIOLOGY 

The  ureter  transmits  the  urine  from  the  kidney  to  the  bladder  by 
its  peristaltic  action. 

Waves  of  contraction  run  along  it  quite  as  along  the  intestine, 
and  as  each  wave  reaches  the  bladder  the  ureteral   orifice  becomes 


URETERAL  NEOPLASMS  453 

slightly  raised  and  tumefied,  emits  a  little  jet  of  urine,  and  then  sinks 
back  again.  This  is  perhaps  the  most  picturesque  phenomenon  observ- 
able through  the  cystoscope.  The  contractions  of  the  two  ureters  are 
quite  independent  and  not  often  synchronous.  They  recur  irregularly 
every  five,  ten^  or  twenty  seconds.  Exceptionally  the  intervals  are 
much  longer. 

Like  the  bladder,  the  ureter  is  insensitive  to  touch  unless  inflamed, 
except  at  its  vesical  orifice.  But,  like  the  bladder,  it  is  extremely  sen- 
sitive to  distention — witness  the  agonizing  pain  of  renal  colic.  Whether 
those  obscure  cases  of  renal  colic  attending  the  passage  of  concentrated 
crystalline  urine  are  due  to  distention  or  to  simple  scratching  of  the 
ureteral  w^alls  it  is  impossible  to  say.  Dr.  Bryson  has  advanced  the 
theory  that  pain  of  the  upper  third  of  the  ureter  is  radiated  to  the 
kidney,  pain  of  the  middle  third  to  the  abdomen,  and  pain  of  the  lower 
third  to  the  bladder  and  urethra.  While  this  is  usually  the  case,  vesical 
pain  of  renal  origin  may  be  due  to  a  disturbance  solely  in  the  renal 
pelvis  without  any  implication  of  the  ureter. 

EXAMINATION 

The  methods  of  examining  the  ureter  are  reducible  to  two:  (1) 
Palpation  (Chapter  I)  ;  (2)  urethral  catheterization  and  its  various 
modifications  (Chapter  V). 

MALFORMATIONS 

These  are  described  on  p.  536. 

URETERITIS  AND  STRICTURE 

Ureteritis,  whether  due  to  pyogenic  bacteria  alone  or  excited  by 
stone  or  tuberculosis,  is  but  a  feature  of  the  larger  renal  condition  and 
is  accordingly  considered  therewith. 

Ureteral  stricture  is  usually  due  to  tuberculosis  or  stone,  less  often 
to  chronic  simple  ureteritis,  to  trauma  (operation)  or  to  congenital 
malformation.  The  stricture  results  in  hydro-  or  pyonephrosis.  A 
pre-operative  diagnosis  may  be  made  by  pyelography.  The  treatment 
is  by  dilatation,  resection  or  nephrectomy  (cf.  p.  701). 

URETERAL  NEOPLASMS 

Cysts  of  the  ureter  are  extremely  rare.  ]\Iucous  cysts  may  occur, 
and  cystitis  cystica  may  extend  up  the  ureters. 


454  THE  URETERS  AND  THEIR  DISEASES 

Epithelial  Growths. — The  solid  neoplasms  of  the  ureter  are  epi- 
thelial formations,  papilloma,  carcinoma,  and  epithelioma.^  These 
tumors  have  been  studied  by  Albarran,-  who  has  collected  65  cases. 
Their  histogenesis  is  quite  the  same  as  that  of  vesical  tumors.  They 
usually  begin  as  seemingly  benign  growths  and  become  malignant  sec- 
ondarily, arising  in  the  renal  pelvis  and  being  propagated  downward  by 
direct  extension  or  by  implantation.  In  the  kidney  they  may  produce 
secondary  deposits  or  give  rise  to  hydronephrosis,  or  pyonephrosis. 
The  kidney,  bladder,  retroperitoneal  glands,  and  the  liver  or  the  pleura, 
may  be  involved  secondarily.  The  youngest  patient  was  twenty-seven 
years  old,  the  oldest  eighty-nine.  In  8  cases  there  was  stone  in  the 
kidney. 

Symptoms. — The  symptoms  are  those  of  renal  stone  or  tumor. 
Bleeding  is  usually  noted  (79  per  cent)  and  is  often  the  first  symp- 
tom. Tumor  was  noted  in  70  per  cent  of  the  cases,  pain  in  60  per  cent. 
The  diagnosis  has  been  made  only  by  the  observation  (through  a  cysto- 
scope)  of  a  villous  tumor  protruding  from  the  ureteral  orifice.  The 
tumor  has  otherwise  been  either  unrecognized  or  mistaken  for  a  renal 
growth. 

Treatment. — The  treatment  is  wholly  operative.  ISTephrectomy 
has  been  performed  21  times,  with  3  deaths  and  8  known  recurrences. 
One  case  of  papilloma  was  known  to  be  well  fourteen  months,  and  2  of 
carcinoma  four  and  six  years  after  operation. 

Inasmuch  as  the  recurrence  almost  invariably  appears  in  the  ureteral 
stump,  the  duct  should  be  removed  entire.  Cystoscopy  will  determine 
whether  a  portion  of  the  adjacent  bladder  wall  should  be  resected  with 
the  tumor. 

URETERAL  FISTULAE 

Ureteral  fistulae  have  many  causes.  Congenital  ureterorectal  and 
ureterovaginal  fistulae  are  extremely  rare.  Acquired  fistulae,  on  the 
contrary,  occur  in  any  portion  of  the  ureter:  at  the  upper  end  after 
nephrectomy,  especially  if  the  ureter  is  actively  tuberculous.  In  other 
parts  of  its  course  cutaneous  fistulae  form  after  the  duct  has  been  inad- 
vertently divided  during  an  abdominal  operation  or  after  rupture  from 
stone,  stricture,  or  other  disease,  such  as  tuberculosis  and  neoplasm, 
or  from  trauma  or  pressure  of  some  intra-abdominal  growth  usually 
of  the  uterus  or  ovary,  or  from  injuries  inflicted  during  labor. 

The  essential  cause  of  the  persistence  of  fistula  in  all  such  cases 
is  obstruction  of  the  ureter,  usually  by  stricture,  between  the  fistula 
and  the  bladder.     If  this  obstruction  is  relieved  the  fistula  will  heal. 

^  Morris  has,  however,  collected  3  reported  cases  of  sarcoma. 
^"Les  tumeurs  du  rein,''  Paris,  1903. 


URETERAL  FISTULAE  455 

The  discharge  from  the  ureteral  fistula  is  usually  uropurulent, 
sometimes  simply  purulent,  and  rarely  simply  urinary.  The  presence 
of  urine  in  the  discharge  may  be  taken  as  presumptive  evidence  that  the 
fistulous  ureter  leads  up  to  a  functionating  kidney.  Yet  the  presence 
of  urine  does  not  prove  a  connection  with  the  kidney,  for  the  urine 
may  regurgitate  from  the  bladder  through  a  ureteral  fistula,  if  the  ureter 
is  gravely  diseased. 

Treatment. — The  treatment  of  cutaneous  fistula  is  nephrectomy  if 
the  kidney  has  ceased  to  functionate,  dilatation  by  ureteral  catheter  or 
ureteral  anastomosis  if  the  kidney  is  worth  saving  (p.  701). 

The  treatment  of  ureterovaginal  and  uretero-uterine  fistula  is  no 
simple  matter.  The  great  variety  of  operations  employed  for  its  cure, 
the  great  proportion  of  failures  after  most  of  these,  and  the  total  absence 
of  concerted  surgical  opinion  upon  the  subject,  attest  the  complexity  of 
the  problem.  Abdominal  ureterocystoneostomy  should  be  tried.  Hys- 
terocleisis  and  colpocleisis  are  operations  of  last  resort.  The  functional 
result  of  including  the  uterus  or  the  vagina  in  the  urinary  reservoir  is 
anything  but  satisfactory.  If  all  attempts  at  ureterovesical  anasto- 
mosis fail  and  the  opposite  kidney  is  healthy,  nephrectomy  is  preferable 
to  colpocleisis. 


CHAPTER    XLVII 

HYDRONEPHROSIS 

Obstkuction  to  the  outflow  of  urine  down  the  ureter  is  of  two 
kinds:  (1)  Sudden  complete  obstruction,  (2)  gradual  or  incomplete 
obstruction. 

Sudden  complete  obstruction  occurs  clinically  under  two  forms, 
viz.,  bj  a  calculus  and  by  the  surgeon's  ligation.  In  either  event  the 
result  is  the  same.  The  urine  is  dammed  back  upon  the  kidney,  causing 
an  acute  renal  congestion  and  a  diminished  secretion  of  urine;  but 
even  this  increases  the  intrarenal  pressure.  The  congestion  is  exchanged 
for  atrophy  after  little  dilatation  has  occurred,  thus  terminating  the 
usefulness  of  the  organ.  The  details  of  these  changes  are  described 
under  Calculous  Anuria. 

Gradual,  incomplete,  or  intermittent  urinary  obstruction  sets  up  a 
very  different  train  of  events.  Some  urine  escapes  past  the  obstruction, 
continuously  or  from  time  to  time,  and  affords  partial  relief  to  the  renal 
tension,  while  still  keeping  up  a  very  considerable  pressure.  Thus  the 
organ  does  not  atrophy.  It  continues  to  excrete  an  amount  of  urine 
equivalent  to  what  can  pass  the  obstruction,  while  the  continued  high 
pressure  within  the  kidney  causes  a  gradual  dilatation  of  its  cavity. 
Pelvis  and  calices  gradually  dilate — and  there  is  hydronephrosis  (cys- 
tonephrosis,  nephrectasis,  renal  distention,  uronephrosis). 

The  above-described  pathogenesis  of  renal  atrophy  and  hydro- 
nephrosis has  been  experimentally  worked  out  by  Guy  on,  ^  Byron  Robin- 
son,^ and  others. 

The  influence  of  infection  in  causing  hydronephrosis  is  not  clear. 
All  specimens  of  grave  chronic  renal  infection  exhibit  some  slight  dila- 
tation of  the  renal  pelvis,  even  though  there  be  no  appreciable  obstruc- 
tion. On  the  other  hand  there  is  a  priori  reason  to  believe  that  grave 
chronic  renal  infection  does  not  occur  in  the  absence  of  all  retention. 
Furthermore  animal  experiments  have  shown  that  infection  is  a  pre- 
dominating cause  of  hydronephrosis.  Even  the  kidney  whose  ureter 
is  closed  by  ligature  becomes  hydronephrotic  if  mildly  infected,  while 
"infection  of  the  non-stenosed  ureter  causes  hydronephrosis"  (Beer  ^). 

^Guyon's  Annates,  1892,  x,  161. 
^Annals  of  Surgery,  1893,  xviii,  402. 
Mm,  J.  Med.  ScL,  June,  1912. 

456 


ETIOLOGY 


457 


ETIOLOGY 


The  cause  of  hydronephrosis  is  gradual,  incomplete,  or  intermittent 
urinary  obstruction.  The  obstruction  may  be  either  urethral  or 
ureteral. 

Urethral  Obstruction. — The  common  urethral  obstructions  are  stric- 
ture and  prostatism.  But  the  former  always  and  the  latter  usually 
damages  the  kidneys  more  by  infection  than  by  dilatation.  The  bladder 
bears  the  brunt  of  the  distention,  and,  although  the  kidneys  and  ureters 
become  dilated  by  chronic  urethral 
obstruction  (Fig.  49),  this  dilatation 
is  clinically  subordinate  to  the  in- 
flammatory features  of  the  disease. 

Ureteral  Obstruction — Ureteral 
obstruction  acts  differently.  Xo  dis- 
tensible bladder  intervenes  to  dis-  ^i^— ^^— . 
tribute  the  pressure,  and  infection  is  ^^^^^^  im 
often  entirely  absent ;  so  that  the 
aseptic  dilatation  of  kidney  and  ure- 
ter progresses  rapidly  and  unob- 
scured; 

The  ureteral  obstructions  are: 

1.  Obstruction  from  within  by 
stone,  tumor,  or  foreign  body  (Fig. 
80). 

2.  Pressure  from  without  by 
aberrant  renal  vessel  (Fig.  98)  or  by 
pelvic  growth. 

3.  Kinking  of  the  ureter  from 
nephroptosis  or  misplaced  kidney. 

4.  Strictures  and  valves  of  the 
ureter,    especially    those    caused    by 

anomalous  origin  of  the  duct  or  by  stricture  at  its  termination. 

5.  Congenital  dilatation  of  the  whole  ureter  with  the  kidney,  either 
with  or  without  stricture  of  the  vesical  orifice. 

6.  Trauma  to  the  kidney  causing  true  or  pseudohydroncphrosis. 

7.  Ureteral  trauma,  whether  partial  division  of  the  duct,  stripping 
it  of  its  blood  supply  (as  in  the  Wertheim  operation),  or  ligature. 
Ligature  with  simple  catgut  leaves  a  pennanent  stricture. 

Eoberts  ^  has  examined  52  cases  in  reference  to  their  etiology. 
Twenty  we're  bilateral  and  32  unilateral.     The  cause  was  congenital 

*" Urinary  and  Kenal  Diseases."  Second  American  Edition,  Philadelphia,  1872, 
p.  482. 


Fig.  98. — Hydronephrosis  from  Ure- 
teral COMP  ESSION  (at  A)  BY  A 
Branch  of  the  Renal  Vein.  This 
obstruction  caused  an  intermittent  hy- 
dronephrosis, which  was  permanently 
cured  by  the  lib  ration  of  adhesions 
and  nephropexy. 


458  HYDRONEPHROSIS 

in  20  cases.  In  2  of  these  a  supernumerary  renal  artery  crossed  and 
compressed  the  ureter  near  its  origin ;  in  4  the  ureter  was  congenitally 
imperforate;  in  4  the  ureter  entered  obliquely  into  the  pelvis  of  the 
kidney ;  in  1  the  ureter  was  kinked  and  adherent ;  in  1  there  was  stric- 
ture at  the  vesical  extremity.  Thirteen  of  these  congenital  cases  were 
bilateral.  Of  these,  2  were  still-born,  5  died  within  six  months  (3 
within  forty-eight  hours)  after  birth.  Four  lived  from  five  and  a  half 
to  twenty  years.     One  ^  survived  to  the  age  of  thirty-eight. 

Of  the  32  cases  of  acquired  hydronephrosis,  11  were  due  to  impacted 
ureteral  calculi  (3  others  were  attributed  to  the  same  cause)  ;  5  showed 
inflammatory  or  ulcerative  stricture;  9  were  occluded  by  external  pres- 
sure— by  peritoneal  adhesions  (3  cases),  gravid  uterus,  ovarian  cyst, 
cancerous  growth. 

Morris  has  analyzed  142  cases,  of  which  128  were  due  to  obstruction 
of  the  ureter,  by  cancer  of  the  pelvic  organs  (118),  cancer  of  the  ab- 
dominal organs  (3),  ovarian  cysts  (4),  and  '^constriction  of  the  ureter" 
(3).  Yet  hydronephrosis  due  to  cancerous  obstruction  is  rarely  noted 
except  post  mortem. 

The  so-called  traumatic  hydronephrosis  is  almost  always  an  encysted 
perinephritic  extravasation. 

A  special  cause  of  hydronephrosis,  a  cause  that  figures  but  rarely  in 
statistics  and  yet  is  commonly  encountered  in  practice,  is  nephroptosis. 
Certainly  renal  mobility  is  associated  with  practically  every  case  of 
intermittent  hydronephrosis,  and  in  a  great  majority  of  hydronephroses 
due  to  kinked  and  adherent  ureters,  whether  over  an  aberrant  renal 
vessel  or  not,  and  to  oblique  implantation  of  the  ureter  in  the  kidney 
pelvis,  the  first  kinking  of  the  ureter  or  pouching  of  the  pelvis  is 
attributable  to  a  nephroptosis  (Fig,  98). 


PATHOLOGY 

The  morbid  conditions  at  the  point  of  ureteral  obstruction  require 
no  detailed  description.  The  strictures,  adhesions,  etc.,  present  no 
peculiar  features. 

The  Hydronephrotic  Sac — The  tumor  may  consist  of  only  a  part 
of  the  kidney,  whether  because  the  kidney  possesses  two  ureters,  only 
one  of  which  is  blocked,  or  because  a  single  calyx  becomes  occluded  by 
a  stone.  Either  condition  is  very  rare ;  as  a  rule,  the  sac  consists  of  the 
entire  kidney  and  its  pelvis.     The  ureter  may  also  be  dilated. 

The  size  of  the  tumor  varies  from  that  of  a  normal  kidney  to  that 
of  a  child's  head. 

The  sac  wall  consists  of  the  renal  pelvis  and  capsule.     The  kidney 

^  Kinkerl  and  adherent  ureters,  doubtless  not  congenital. 


PATHOLOGY  459 

caps  the  tumor.  The  outer  surface  of  the  mass  is  irregularly  ovoidal, 
the  inner  surface  is  irregular.  If  the  hydronephrosis  is  small  its  in- 
terior consists  of  the  dilated  pelvis  and  calices  (Fig.  98).  If  large,  it 
is  a  great,  smooth-walled  cavity  crossed  by  fibrous  septa  representing  the 
remains  of  the  columns  of  Bertini  (Fig.  39).  The  sac  wall  may  be 
thin,  but  is  usually  tough  and  fibrous.  Cartilaginous  nodules  have  been 
observed  in  it. 

Renal  Changes, — The  changes  in  the  kidney  substance  are  interest- 
ing. At  first  the  kidney  is  congested,  the  canaliculi  dilated,  and  the 
cells  flattened.  This  process  soon  manifests  itself  macroscopically  by 
the  thinning  out, of  the  kidney  tissue.  Thus  the  kidney  becomes  more 
and  more  spread  out  on  the  surface  of  the  sac  with  a  great  portion  of 
its  secreting  substance  atrophied.-^  But  this  is  not  the  only  change. 
The  remaining  parenchyma  cells— for  the  kidney  is  never  completely 
atrophied — undergo  a  compensatory  hypertrophy.  They  grow  to  three 
or  four  times  their  normal  size  and  their  secretory  capacity  increases 
accordingly.  It  is  for  this  reason  that  every  hydronephrotic  kidney 
should  be  recognized  as  a  useful,  though  an  impaired,  organ,  and  should 
not  be  sacrificed  unnecessarily. 

The  hydronephrotic  sac  may  be  open  or  closed.  If  the  ureter  is 
merely  kinked,  the  hydronephrosis  is  usually  intermittent.  If  con- 
tractured  or  obstructed,  the  hydronephrosis  is  fixed  or  constant,  and  the 
orifice  of  the  sac  may  finally  become  absolutely  sealed. 

The  Fluid — The  normal  kidney  pelvis  will  hold  from  two  to  eight 
c.c.  A  pelvis  that  will  hold  more  than  10  c.c.  is  dilated.  The  quantity 
of  fluid  in  a  hydronephrotic  sac  may  reach  5  or  6  gallons.  One  case  is 
reported  (Glass)  containing  30  gallons. 

The  quality  of  the  fluid  varies.  A  large  ancient  fixed  hydrone- 
phrosis usually  contains,  a  simple  solution  of  sodium  chlorid,  though  it 
may  contain  urea,  albumin,  urinary  crystals,  epithelial  cells,  and  leuko- 
cytes, and  less  often  blood  or  cholesterin. 

There  may  be  a  catarrhal  pyelonephritis,  with  slight  infection  of 
the  contents  of  the  sac  (infected  hydronephrosis).  This  light  infection 
does  not  materially  influence  the  clinical  aspect  of  the  case,  but  hastens 
the  destruction  of  renal  parenchyma. 

Physiology. — The  hydronephrotic  kidney  secretes  a  urine  less  rich 
in  solids  than  that  of  a  normal  organ ;  but  Guyon  and  Albarran  ^  have 
shown  that  even  the  kidney  whose  ureter  has  been  occluded  for  a  great 
while  will  begin  to  secrete  when  the  obstruction  is  removed.  Urea 
appears  in  the  secretion,  though  it  may  have  been  entirely  absent  from 
the  fluid  in  the  sac;  while  the  quantity  of  fluid  secreted  by  the  diseased 

^  There  is  no  interstitial  sclerosis,  no  production  of  fibrous  tissue,  in  simple 
uninflamed  hydronephrosis. 

'  Guyon's  Annales,  1897,  xv,  1200. 


460  HYDRONEPHROSIS 

organ  is  excessive  as  soon  as  the  pressure  of  retention  is  relieved.  In 
one  case  (infected)  in  which  the  renal  tissue  was  so  compressed  that  it 
was  only  2  or  3  mm.  thick,  the  kidney  excreted  a  liter  a  day  after  the 
pressure  had  been  removed. 

The  kidney  whose  outlet  has  not  been  entirely;  closed  acts  in  a  similar 
manner.  While  a  normal  quantity  of  urine  may  be  excreted  by  the 
diseased  organ,  it  is  poorer  in  urea  and  salts.  It  usually  contains  one- 
quarter  to  one-third  of  the  total  urea.  While  the  total  excretion  of  urea 
may  vary  widely  from  day  to  day,  this  variation  takes  place  almost 
entirely  in  the  sound  kidney,  the  diseased  organ  excreting  an  approxi- 
mately constant  amount. 

SYMPTOMS 

Many  kidneys  found  hydronephrotic  post  mortem  give  no  symptoms 
during  life.  The  one  characteristic  symptom  by  which  attention  is 
called  to  the  kidney  is  the  presence  of  a  tumor.  There  are  clinically 
two  varieties  of  hydronephrosis.  When  the  tumor  is  constant  the  hydro- 
nephrosis is  spoken  of  as  fixed ;  when  the  tumor  varies  in  size  the  hydro- 
nephrosis is  said  to  be  intermittent. 

Fixed  Hydkonephrosis. — ^When  the  hydronephrosis  is  fixed  the 
patient  usually  gives  a  history  of  a  slowly  growing  tumor  in  his  side. 
Or  soreness  and  pain  may  first  call  attention  to  the  kidney;  but,  as  a 
rule,  unless  the  kidney  is  misplaced  and  adherent,  fixed  hydronephrosis 
is  uncomfortable  rather  than  painful.  The  tumor  grows  very  slowly. 
It  may  burst  either  into  the  peritoneal  cavity  or  into  the  perirenal  space ; 
either  event  is  rare  (cf.  Babitski^). 

On  examination  a  smooth,  elastic,  fairly  movable,  and,  as  a  rule, 
insensitive  tumor  is  found  filling  the  side.  The  absence  of  systemic 
disturbance  is  remarkable.  There  is  no  fever,  and,  unless  both  kidneys 
are  affected,  no  evidence  of  renal  insufficiency. 

Intermittent  Hydronephrosis.— This  condition  presents  an  entirely 
different  picture.  The  trouble  begins  with  irregular  attacks  of  severe 
pain  in  the  side.  These  pains  are  habitually  attributed  to  the  intes- 
tines, to  hysteria,  or  to  renal  colic.  When  the  patient  is  examined 
between  attacks  the  discovery  of  a  movable  and  tender  kidney  confirms 
the  diagnosis  of  hysteria,  and  if  the  patient  becomes  thin  and  anemic 
and  has  flushes  of  watery  urine,  thi  3  only  adds  color  to  the  picture. 

But  affairs  go  from  bad  to  worso.  The  attacks  of  pain  become  more 
and  more  severe,  they  recur  every  few  days.  During  the  attack  the 
distended  kidney  may  be  felt  filling  the  entire  loin.  The  pain,  after 
lasting  several  hours  or  days,  is  suddenly  relieved  by  the  passage  of  a 
large  quantity  of  urine ;  but  the  relief  is  only  temporary.     At  the  end 

^  ArcMv  f.  Iclin.  Chir.,  1912,  xcvii,  No.  4. 


DIAGNOSIS  461 

of  the  usual  interval  the  pain  recurs.  In  a  personal  case  the  pains 
began  twenty  years  before  the  tumor  was  found,  while  in  another 
the  tumor  reached  enormous  dimensions  after  less  than  ten  years' 
growth. 

Hematuria  is  an  unusual  but  striking  feature  of  some  cases.  The 
hemorrhage  may  be  repeated  and  profuse. 

Morris  justly  remarks  that  not  all  these  cases  are  due  to  renal  mobil- 
ity, and  cites  instances  attributed  to  stone  and  to  vesical  papilloma. 
Yet  Terrier  and  Baudouin,  who  collected  83  reported  cases,  showed  that 
the  condition  was  almost  always  associated  with  nephroptosis." 

The  usual  outcome  of  an  intermittent  hydronephrosis  is  that  it  be- 
comes fixed.  The  variations  in  size  decrease  and  the  pain  becomes  more 
constant  and  less  severe. 

DIAGNOSIS 

It  is  scarcely  possible  to  mistake  a  fully  developed  intermittent 
hydronephrosis.     The  large  recurrent  lumbar  tumor  is  characteristic. 

A  fixed  hydronephrosis  may  be  distinguished  as  a  chronic  nonin- 
flammatory renal  tumor.  When  large  the  cystic  nature  of  the  gTowth  is 
obvious.  It  may  then  be  mistaken  for  ovarian  cyst.  When  small,  it  is 
not  always  possible  to  distinguish  a  hydronephrosis  from  other  tumors 
of  the  kidney.  The  occurrence  of  hematuria  may  confuse  the  clinical 
picture. 

Accurate  diagnosis  is  made  by  the  ureter  catheter. 

The  urine  obtained  from  the  hydronephrotic  kidney  always  shows 
some  deficiency  of  urea  and,  unless  the  kidney  is  almost  wholly  de- 
stroyed, an  increase  in  quantity  as  compared  with  its  fellow  (unless  the 
condition  is  bilateral).  The  phenolsulphonephthalein  output  is  much 
more  markedly  interfered  with  than  that  of  urea. 

If  the  ureter  catheter  can  elude  the  ureteral  obstruction  and  enter 
the  kidney  pelvis,  the  presence  of  hydronephrosis  is  immediately  at- 
tested by  a  free  flow  of  urine.  This  flow  does  not  measure  the  capacity 
of  the  kidney  pelvis  for  this  cavity  may  not  be  distended  at  the  time 
of  catheterization.  But  however  empty  it  may  be  there  is  always  some 
residual  urine  present.  To  measure  the  capacity  of  the  renal  pelvis 
by  filling  it  with  fluid  introduced  through  the  ureter  catheter  is  a 
dangerous  experiment  and  has  after  all  no  value,  for  there  is  no  advan- 
tage in  knowing  the  precise  size  of  the  hydronephrosis.  Moreover  a 
much  more  accurate  picture  is  obtained  by  pyelography. 

Since  ureteral  peristalsis  is  lost  above  the  ureteral  obstruction,  the 
situation  of  this  may  be  estimated  from  the  point  at  which  the  urine 
flows  in  a  constant  stream  as  though  the  end  of  the  catheter  were  in 
the  kidney  pelvis. 


462  HYDRONEPHROSIS 

If  the  catheter  will  not  pass  the  ureteral  obstruction,  even  if  no 
urine  is  obtained,  pyelography  is  again  our  salvation. 

Thus  pyelography  is  the  last  resort  for  an  accurate  diagnosis.  It 
should  only  be  performed  with  the  patient  in  the  hospital,  ready  to  be 
operated  upon  if  occlusion  of  the  ureter  results.  Through  it  we  may 
obtain,  not  only  a  precise  picture  of  the  dilatation  of  the  kidney  pelvis 
and  of  its  ureter,  but  also  considerable  information  as  to  whether  the 
ureteral  obstruction  is  due  to  a  kinking  of  that  canal  or  an  actual 
stricture. 

It  is  not  to  be  forgotten  that  many  of  the  smaller  renal  dilatations 
are  actually  not  hannful  to  the  patient  so  long  as  they  drain  freely  into 
the  ureter.  A  sharp  angulation  at  the  junction  of  ureter  and  kidney 
pelvis  and  a  convexity  of  the  lower  border  of  the  kidney  pelvis  (the 
so-called  ''derby  hat"  pelvis)  suggests  that  drainage  is  not  perfect. 
It  is  further  to  be  noted  that  the  normal  ureter  (with  the  patient  on 
his  back)  drops  in  practically  a  straight  line  from  the  kidney  pelvis 
to  the  brim  of  the  bony  pelvis. 

The  practice  of  taking  pyelograms  with  the  patient  erect  so  as  to 
bring  out  the  kinking  and  convolution  of  the  ureter  has  led  to  many 
mistakes  in  diagnosis,  for  the  kinks  and  convolutions  thus  produced  are 
not  always  pathological.  Deductions  should  therefore  be  drawn  only 
from  pictures  taken  with  the  patient  lying  on  his  back. 


PROGNOSIS 

Unless  both  kidneys  are  affected  hydronephrosis  does  not  threaten 
life.  The  development  of  the  tumor  is  very  slow,  and  treatment  is  usu- 
ally demanded  for  the  relief  of  pain.  Infection  may  occur,  transform- 
ing the  hydronephrosis  into  an  infected  hydronephrosis  (common),  or 
into  a  pyonephrosis  (rare).  Rupture  of  the  sac  is  most  exceptional. 
Morris  noted  the  spontaneous  and  permanent  disappearance  of  6  or  7 
out  of  47  hydronephroses  observed  by  him. 


TREATMENT 

Slight  dilatations  of  the  renal  pelvis,  up  to  a  content  of  approxi- 
mately 20  or  30  c.c,  require  no  treatment  unless  they  are  sufficiently 
infected  to  cause  toxemia  or  unless  there  is  kidney  pain.  If  these  symp- 
toms are  absent  such  dilatations,  accidentally  discovered  during  ureter 
catheterization,  may  be  noted  but  certainly  require  no  treatment. 

On  the  other  hand,  retention  of  small  amounts  of  urine  in  the  renal 
pelvis,  like  similar  retention  in  the  bladder,  may  cause  symptoms  of 


PLATE    XVII 


TREATMENT  463 

considerable  severity.  Under  these  circumstances,  it  will  be  found 
that  the  ureter  does  not  drain  the  pelvis  well.  Such  hydronephroses 
are  usually  intermittent.  The  treatment  of  such  cases  should  be  deter- 
mined after  the  nature  of  the  obstruction  has  been  studied  by  pyelog- 
raphy. If  the  ureteral  obstruction  is  a  kink  it  can  only  be  relieved  by 
operation;  if  it  is  a  stricture,  it  may  be  relieved,  temporarily  at  least, 
by  the  indwelling  catheter  or  by  dilatation  with  ureter  catheters  of  dif- 
ferent sizes.  Ureter  stricture,  like  urethral  stricture,  may  often  be 
readily  dilated  and  will  sometimes  remain  dilated  for  years.  But  the 
patient  should  be  warned  of  the  possibility  of  relapse. 

Hydronephrosis  due  to  urethral  obstniction  can  usually  be  relieved 
by  the  cure  of  this  obstruction,  though  in  some  cases  a  secondary  ureteral 
obstruction  will  have  to  be  dealt  with  surgically. 

Hydronephroses  of  larger  content,  due  to  ureteral  obstruction, 
always  cause  symptoms  and  call  for  operative  relief.  This  relief  may 
be  of  two  kinds :  by  removal  of  the  obstruction,  lin*  by  nephrectomy. 
Such  cases  may  be  grouped  into  three  classes. 

When  both  kidneys  are  affected,  and  pyelography  shows  a  type  of 
retention  that  cannot  be  relieved  by  ureter  catheter  or  plastic  operation, 
the  bilateral  impairment  of  renal  function  may  be  such  as  to  forbid 
the  removal  of  either  kidney.  Under  these  circumstances,  the  only 
operation  to  be  contemplated  is  bilateral  nephrostomy.  It  may  be  often 
deemed  wiser  to  do  nothing. 

In  a  second  class  of  cases,  the  hydronephrosis  is  unilateral,  the 
function  of  the  kidney  reduced  almost  to  zero,  its  parenchyma  almost 
totally  destroyed,  and  its  pelvis  pouched  in  a  complex  manner.  Under 
these  circumstances,  one  may  well  conclude  that  no  plastic  operation 
will  really  relieve  the  renal  retention,  and  that  the  kidney  is  scarcely 
worth  saving.     ISTephrectomy  is  the  operation  of  choice. 

In  a  third  class  of  cases,  the  kidney  is  by  no  means  totally  destroj^ed, 
and  the  ureteral  obstruction  may  be  more  or  less  readily  relieved.  If 
the  latter  is  due  to  nephroptosis,  to  stone,  to  contraction  of  the  uretero- 
vesical meatus,  to  kinking  of  the  ureter  by  adhesions  or  over  an  ab- 
normal vessel,  the  indication  for  a  plastic  operation  is  obvious.  Such 
obstructions  may  be  readily  relieved  with  a  large  chance  of  success. 
But  the  prospect  of  successfully  relieving  the  obstruction  may  be  inter- 
fered with  in  several  ways.  Most  important  of  these  is  the  condition  of 
the  opposite  kidney.  If  this  is  such  that  nephrectomy  would  seem  inad- 
visable or  unjustifiable  the  operative  indication  must  be  very  precise 
and  the  operator  very  sure  of  his  success  before  any  surgery  is  at- 
tempted ;  for  the  failure  of  a  plastic  operation  under  such  conditions,  by 
condemning  the  patient  to  nephrectomy,  would  perhaps  condemn  him 
to  death. 

But  if  the  condition  of  the  opposite  kidney  is  good,   almost  any 


464  HYDRONEPHROSIS 

plastic  operaticn  may  be  attempted  witli  the  assurance  tliat  if  this  fails, 
and  nephrectomy  is  called  for,  this  at  least  will  not  prove  fatal. 

The  various  plastic  operations  that  may  be  required  for  the  relief 
of  hydronephrosis  are  described  in  another  place.  The  plastic  removal 
of  spurs  in  the  renal  pelvis,  caused  by  the  so-called  "high  implantation 
of  the  ureter  in  the  kidney  pelvis"  is  not  always  easy  of  performance, 
and  the  resulting  scar  sometimes  leaves  the  retention  as  bad  as  ever. 
An  indwelling  catheter  should  always  be  left  in  place  at  the  close  of 
such  an  operation.  Transplantation  of  the  ureter  into  the  bladder  is 
an  even  less  satisfactory  procedure.  In  spite  of  the  most  careful  technic 
the  drainage  is  likely  to  be  imperfect,  the  ureter  often  becomes  infected, 
and  in  fully  half  the  cases  the  kidney,  after  going  through  a  period  of 
acute  infection,  at  least  becomes  useless  as  an  excretory  organ,  or  at 
worst  suppurates  so  acutely  as  to  require  nephrectomy. 

On  the  other  hand,  the  relief  of  hydronephrosis  due  to  stone  in  the 
ureter,  or  to  adhesions  and  kinking  about  the  ureteropelvic  junction,  is 
one  of  the  most  satisfactory  operations  in  renal  surgery,  while  the 
relief  of  congenital  stricture  at  the  lower  end  of  the  ureter  by  cysto- 
scopic  incision  of  the  ureter  mouth  is  readily  achieved. 

Eliot  ^  has  collected  the  reports  of  77  plastic  operations  upon  the 
upper  end  of  the  ureter  for  the  relief  of  hydronephrosis;  27  of  them 
failed,  50  resulted  in  immediate  successes;  but  only  11  of  these  were 
verified  by  subsequent  examinations.  In  only  3  cases  was  the  condition 
of  the  kidney  verified  more  than  a  year  after  operation;  two  of  these 
showed  a  normal  function  at  2  and  5  years  respectively,  a  third  showed 
a  somewhat  diminished  function  7  years  after  operation. 

^Jour.  d'Urol.,  1913,  iii,  161. 


CHAPTEE    XLVIII 
PHYSIOLOGY  AND  VARIOUS  DISEASES  OF  THE  BLADDER 

PHYSIOLOGY 

Capacity — The  capacity  of  the  bladder  is  physiological,  not  ana- 
tomical (Guyon).  Although  in  actual  size  the  healthy  bladders  of 
different  individuals  do  not  differ  materially,  the  actual  capacity  of 
the  organ  depends  upon  its  sensitiveness,  and  this  sensitiveness  varies 
at  different  times  and  with  different  individuals.  The  physiological 
capacity  of  the  bladder — the  amount  of  urine  which  an  ordinary  blad- 
der holds  when  the  desire  to  urinate  is  first  felt — is  about  250  c.c. 
(8  ounces). 

Sensitiveness — The  healthy  bladder  is  quite  insensitive  to  touch, 
except  about  the  orifices  of  the  ureters  and  the  urethra,  but  very  sensi- 
tive to  tension.  Thus  a  sound  may  be  poked  about  in  the  bladder  and 
cause  no  sensation  whatever  except  in  the  prostatic  urethra.  On  the 
other  hand,  the  torture  of  "holding  water"  requires  no  comment.  The 
sensitiveness  of  the  bladder  may  be  diminished  by  habit ;  beer-guzzlers 
and  diabetics  may  not  urinate  more  often  than  those  who  pass  perhaps 
only  half  as  much  urine.  The  sensitiveness  is,  on  the  other  hand, 
increased  by  nervousness  and  by  inflammation. 

Absorption. — Although  the  point  is  disputed,  it  is  probable  that  the 
mucous  membrane  of  the  healthy  bladder  is  practically  as  impervious 
as  the  skin.  But  fluids  are  rapidly  absorbed  through  the  mucous  mem- 
brane of  the  posterior  urethra,  and  also  through  the  bladder  epithelium 
when  inflamed. 

Contraction:  Urination — "Man  urinates  with  his  bladder,  not  with 
his  urethra,"  says  Guyon. 

The  mechanism  of  urination  has  been  illuminated  by  fluoroscopy 
with  this  organ  distended  by  some  visible  fluid.  The  posterior  urethra 
remains  empty  as  the  bladder  distends.  The  desire  to  urinate  is 
associated  with  a  contraction  of  the  bladder  which,  if  the  impulse  is 
resisted,  passes  over  and  returns  with  increased  intensity.  ISTo  urine 
flows  into  the  posterior  urethra  until  urination  actually  begins. 

Curiously  enough  suprapubic  prostatectomy,  by  destroying  the  in- 
ternal sphincter,  leaves  the  posterior  urethra  a  funnel-shaped  cavity. 

4C5 


466         PHYSIOLOGY  AND  VARIOUS  DISEASES  OF  BLADDER 

As  the  bladder  fills  the  posterior  urethra  fills  with  it.     After  prostatec- 
tomy, therefore,  the  urine  is  retained  solely  by  the  external  sphincter.^ 


INCONTINENCE  OF  URINE 

Incontinence  of  urine,  or  enuresis,  is  that  condition  in  which  the 
urine  flows  involuntarily  out  of  the  bladder  as  soon  as  it  flows  in.  Incon- 
tinence must  be  distinguished  from  overflow.  In  each  there  may  be  a 
continual  involuntary  dribbling;  but  in  the  one  case  the  bladder  is 
empty,  in  the  other  it  is  full.  Enuresis  shows  that  the  vessel  leaks; 
overflow  shows  that  the  outflow  pipe  is  obstructed.  In  the  adult  male 
dribbling  of  urine  almost  always  signifies  overflow.  If  there  is  true 
incontinence  the  urine  flows  away  without  any  pain  or  desire  to  urinate. 
Imperative  urination,  when  the  inflamed  bladder  contracts  every  few 
minutes  with  a  force  that  the  cut-off  muscle  cannot  oppose,  is  spoken  of 
as  false  incontinence. 

Incontinence  may  be  partial  or  complete,  diurnal  or  nocturnal. 

Incontinence  in  Adult  Males — Stagnation  with  overflow  and  false 
incontinence  have  been  already  considered.  True  incontinence  depends 
upon : 

1.  Postoperative  enuresis,  from  overcutting  the  vesical  sphincters. 

2.  Paralysis  of  the  bladder. 

3.  Tuberculosis  of  the  neck  of  the  bladder. 

4.  Persistence  of  infantile  incontinence. 

Incontinence  in  Adnlt  Females. — ^Women  have  weaker  bladder 
sphincters  than  men,  and  among  them  such  lesser  irritations  as  uterine 
displacements,  the  pressure  of  tumors,  and  even  trigonitis,  may  excite  a 
most  persistent  and  annoying  incontinence  of  urine. 


ENURESIS  OF  CHILDHOOD 

Infants  have  little  or  no  control  over  their  urination,  especially  at 
night,  but  after  they  leave  off  diapers  they  are  expected  to  stop  wetting 
the  bed.  There  are  doubtless  few  children  who  fulfill  this  expectation 
entirely.  Up  to  the  age  of  five  or  six  an  occasional  accident  may  occur 
to  the  most  normal  child.  But  this  is  not  enuresis.  The  true  nocturnal 
enuresis  of  children — for  it  is  only  exceptionally  diurnal — is  not  no- 
ticed, as  a  rule,  until  the  child  is  five  or  six  years  old.  Then  he  begins 
to  wet  his  bed  quite  regiilarly,  perhaps  two  or  three  times  every  night. 
He  may  also  lose  his  urine  involuntarily  by  day,  and  very  rarely  the 
incontinence  occurs  only  by  day  and  not  by  night. 

^Cf.  Cecil-  •^"'"»--  A.  M.  A.,  1915,  Ixv,  1436. 


ENURESIS  OF  CHILDHOOD  467 

Etiology — The  cause  of  enuresis  is  sometimes  obvious  enough,  but 
usually  obscure. 

1.  Enuresis  due  to  congenital  deformity  such  as  epispadias  is 
readily  diagnosed. 

2.  Enuresis  due  to  tuberculosis  or  stone  is  overlooked  with  sing-ular 
frequency.  The  little  patient  cries  out  when  he  urinates  and  complains 
of  various  pains,  but  the  physician  often  fails  to  consider  the  symptoms 
and  neglects  to  examine  the  urine.  IsTeedless  to  say  a  careful  urinary 
examination  for  pus  and  other  elements  should  precede  the  treatment 
of  any  case. 

3.  Many  cases  are  associated  with  phimosis,  pin  worms,  adenoids, 
hypertrophied  tonsils,  and  other  of  the  minor  diseases  of  childhood. 
The  enuresis  may  often  be  relieved  by  their  removal  and  is  therefore 
usually  spoken  of  as  reflex.  Without  quarreling  about  the  treatment, 
one  may  question  the  theory.  These  little  lads  are  often  thin  and 
anemic  and  their  enuresis  is  apparently  due  to  this  general  condition 
rather  than  actually  reflex. 

4.  In  general  it  may  be  said  that  a  child  with  enuresis  who  is  below 
par  should  be  a  subject  for  hygiene  in  the  hope  that  the  improvement 
of  his  general  condition  may  relieve  the  bed  wetting. 

5.  Enuresis  is  rarely  associated  with  such  nervous  disorders  as 
chorea,  tabes,  etc. 

6.  There  remains  a  large,  perhaps  the  large,  class  of  patients  still 
unaccounted  for.  Their  adenoids  have  been  removed,  they  are  not 
anemic,  deformed  or  tuberculous,  their  urine  contains  no  pus,  and  their 
nervous  system  is  intact.  The  cause  of  enuresis  in  these  cases  is 
unknown. 

The  three  latest  theories  to  account  for  it  are:  (1)  Insufficient 
nervous  impulse,   (2)   thyroid  insufficiency,   (3)  mild  tuberculosis. 

Prognosis.- — Even  though  all  treatments  fail,  the  prognosis  is  ex- 
cellent. With  the  advent  of  puberty  the  child  is  almost  certain  to  stop 
bed  wetting. 

Treatment. — As  has  been  stated  above,  the  treatment  of  the  enuresis 
should  be  preceded  by  a  careful  examination  of  the  patient  for  enlarged 
adenoids  or  tonsils,  for  pin  worms,  for  adhesions  of  foreskin  or  clitoris, 
the  urine  should  be  collected  and  examined  for  albumin  and  sugar,  and 
for  pus  and  bacteria.  If  pus  is  found,  stone  or  tuberculosis  may  be 
suspected.  The  blood  should  be  examined  for  anemia,  and  the  child 
carefully  gone  over  for  evidences  of  tabes  or  chorea. 

In  most  instances,  the  examination  will  fail  to  reveal  any  of  these 
conditions,  and  we  are  left  with  the  so-called  idiopathic  enuresis.  Many 
devices  have-  been  suggested  and  successfully  employed  for  the  treat- 
ment of  these  cases ;  such  as  the  cutting  down  of  the  amount  of  water 
drunk,  especially  after  three  o'clock  in  the  afternoon,  getting  the  child 


468        PHYSIOLOGY  AND  VARIOUS  DISEASES  OF  BLADDER 

into  good  habits  bj  wakening  it  at  night  to  urinate,  and  actually  inter- 
fering with  urination  by  some  form  of  urethral  compressor  placed  on 
the  penis  at  night.  (If  such  machinery  is  to  be  used,  the  parents 
should  be  carefully  instructed  so  that  no  harm  shall  be  done  to  the 
child.) 

If  these  remedies  fail,  we  may  have  recourse  (with  little  hope  of 
success,  I  confess)  to  drugs  empirically  employed.  Extract  of  bella- 
donna, beginning  with  a  dose  of  gr.  1/10,  and  increasing  until  the  pupils 
or  the  throat  show  the  physiological  effect,  is  well  spoken  of.  Perlis 
states  he  cured  102  out  of  156  cases  by  administering  rhus  aromatica; 
he  employs  the  fluid  extract  in  doses  of  from  10  to  80  minims.  I  have 
used  both  of  these  remedies  without  success.  One  may  turn  with 
more  confidence  to  treatment  founded  upon  a  definite  theory.  Thus 
if  we  believe  in  the  lack  of  nervous  impulse,  this  may  be  stimulated  by 
Cathelin's  suggested  injection  of  20  c.c.  of  normal  salt  solution  into 
the  sacral  canal.  This  I  have  tried  several  times  without  success.  Or 
we  may  try  faradization  of  the  membranous  urethra  by  means  of  a 
urethral  electrode  or  stimulation  of  the  nerve  endings  by  instillations 
of  a  few  drops  of  strong  silver  nitrate  solution  into  the  posterior  urethra. 
These  treatments  I  have  also  employed  in  vain. 

Hertoghe  and  Williams  ^  claim  excellent  results  from  the  use  of 
thyroid  extract  in  small  doses.  To  children  between  2  and  6  years  of 
age,  ^  gr.  of  dried  thyroid  extract  may  be  given  twice  a  day;  for  the 
older  children  the  dose  may  be  gradually  increased  to  four  or  five 
times  as  much. 

Keersmacher  claims  excellent  results  from  treating  enuresis  on  the 
theory  that  it  is  a  manifestation  of  slight  general  or  pulmonary  tuber- 
culosis. He  states  that  his  patients  usually  show  a  slight  evening  rise 
of  temperature,  and  positive  von  Pirquet  test.  He  administers  tuber- 
culin in  the  usual  manner,  and  states  that  his  results  are  excellent. 


POSTPROSTATECTOMY  ENURESIS 

Incontinence  of  urine  may  follow  any  operation  upon  the  prostate 
or  bladder  neck.  It  is  so  much  more  often  seen  as  a  result  of  perineal 
prostatectomy  than  after  any  other  operation  that  it  seems  not  invidious 
so  to  label  it.     Its  cause  is  most  obscure,  witness  the  following  facts : 

1.  It  does  not  follow  perineal  section  for  stricture,  even  though  the 
membranous  urethra  is  divided  from  end  to  end. 

2.  It  does  not  follow  suprapubic  prostatectomy,"  even  though  the 

^Lancet,  May  1,  1909,  p.  1245. 

'Though  it  must  be  admitted  that  partial  incontinence  may  rarely  follow  supra- 
pubic prostatectomy. 


PARALYSIS  OF  THE  BLADDER  469 

internal  sphincter  is  freely  divided  and  the  whole  prostatic  urethra 
torn  away. 

3.  It  does  follow  Bottini's  operation,  which  divides  only  the  internal 
sphincter. 

4.  It  is  seen  after  Chetwood's  operation  and  perineal  prostatectomy. 

5.  It  occurs  almost  as  often  after  simple  operations  as  after  com- 
plex and  destructive  ones. 

Doubtless,  therefore,  the  physical  basis  of  incontinence  is  operative 
disturbance  of  any  part  of  the  sphincteric  mechanism.  Some  are  incon- 
tinent by  day,  others  by  night. 

Treatment.- — Incontinence  during  the  first  weeks  after  operation  is 
unimportant.  The  patient  should  be  reassured  and  a  complete  cure 
hoped  for.  But  if  the  incontinence  persists  much  good  may  be  done 
by  filling  the  bladder  with  an  unirritating  solution  and  then  training 
the  patient  by  bidding  him  "start — stop — start — stop"  until  the  bladder 
is  empty. 

Instillations  of  silver  nitrate  are  distinctly  useful  until  the  urethro- 
scope shows  the  posterior  urethra  to  be  entirely  healed. 

If,  at  the  end  of  six  months,  the  patient  is  still  incontinent  the 
membranous  urethra  should  be  sutured.  I  have  thrice  performed  this 
operation  with  two  failures  and  one  success. 


PARALYSIS  OF  THE  BLADDER 

True  paralysis  of  the  bladder  is  one  of  the  gravest  complications  of 
fracture  of  the  spine  and  other  injuries  and  diseases  to  the  lower  spinal 
cord.  Under  such  circumstances,  the  cause  of  the  condition  is  obvious 
enough,  and  its  treatment  futile  unless  the  spinal  lesion  can  be  cured. 

Of  singular  interest,  however,  is  that  paralysis  of  the  bladder  which 
results  from  tabes.  This  is  not  infrequently  one  of  the  earliest  lesions 
of  tabes.  It  occurs  usually  at  a  period  of  life  but  little  antecedent  to 
that  when  prostatism  is  common.  Consequently  it  is  often  mistaken 
for  prostatism  by  the  most  accurate  observers.  I  have  recently  seen 
several  cases  with  paralysis  of  the  bladder  due  to  tabes  who  gave  no 
history  of  syphilis,  and  no  evidence  of  the  disease  excepting  the  para- 
lyzed bladder,  absence  of  deep  muscular  sensibility,  and  absence  of 
ankle  jerk.  All  of  the  other  reflexes  were  entirely  normal,  the  blood 
was  negative  to  Wassermann  reaction ;  but  the  spinal  fluid  showed  the 
characteristic  lymphocytosis  and  positive  Wassermann  reaction. 

The  symptoms  of  this  condition  are  comparable  to  those  of  prosta- 
tism ;  inasmuch  as  retention  of  urine  is  one  of  the  striking  features. 
In  the  clinical  history,  however,  it  will  often  be  noted  that  the  lack  of 
deep  muscular  sensation  while  permitting  these  patients  to- go  around 


470        PHYSIOLOGY  AND  VARIOUS  DISEASES  OF  BLADDER 

with  greatly  distended  bladders  and  little  discomfort  also  permits  them 
to  urinate  with  great  infrequency.  Indeed,  one  occasionally  learns  that 
the  patient  cannot  urinate  at  all  until  the  bladder  fills  to  almost  over- 
flowing; then,  by  an  effort,  urination  can  be  started,  and  the  bladder 
entirely  emptied.  The  condition  may  be  suspected  when  rectal  examina- 
tion and  cystoscopy  fail  to  show  a  prostatic  enlargement  adequate  to 
explain  the  retentio-n  of  urine.  It  may  also  be  suspected  when  there 
is  a  striking  variation  in  the  amounts  of  retained  urine,  when  the  fre- 
quency of  urination  does  not  compare  with  the  amount  of  retained 
urine,  when  there  is  a  history  of  syphilis,  and  of  lack  of  sexual  power, 
when  the  trabeculation  of  the  bladder  is  out  of  all  proportion  to  the 
prostatic  enlargement. 

It  has  been  frequently  stated  that  a  certain  type  of  trabeculation, 
most  clearly  marked  about  the  ureter  orifices^  is  characteristic  of  tabes. 
This  is  by  no  means  the  case. 

The  diag-nosis  is  made  by  an  examination  of  the  reflexes,  notably 
the  ankle  jerk,  and  of  the  spinal  fluid,  and  by  cystoscopy. 

Prostatism  and  paralysis  may,  of  course,  co-exist. 

Infection  occurs  early  and  dilatation  and  infection  of  the  kidneys 
follow  just  as  they  do  in  prostatism.  But  the  management  of  these 
cases  by  the  catheter  is  much  more  successful  than  it  is  when  the  pros- 
tate is  enlarged. 

The  prognosis  of  tabes  itself  is  intimately  bound  up  with  the  prog- 
nosis of  these  bladder  and  renal  infections.  Barney  ^  states  that  50 
per  cent  of  all  tabetics  die  of  renal  infection  and  insufficiency. 

Treatment — The  essential  treatment  is  that  of  the  tabes.  If  the 
bladder  paralysis  is  not  of  long  duration,  one  may  hope  that  a  vigorous 
antisyphilitic  treatment  will  control  the  tabes,  and  relieve  the  paralysis 
of  the  bladder  muscle  at  least  to  the  extent  of  penuitting  the  bladder  to 
empty  itself. 

While  awaiting  this  cure,  the  patient  should  be  regularly  catheter- 
ized,  often  enough  to  keep  the  bladder  from  becoming  overdistended, 
and  should  receive  appropriate  treatment  by  bladder  irrigation  and 
hexamethylenamin. 

By  close  attention  to  the  detail  of  systematic  catheterization,  and 
the  employment  of  such  combinations  of  hexamethylenamin  and  irriga- 
tion of  the  bladder  as  best  suited  each  individual  case,  I  have,  in  a 
number  of  instances,  succeeded  in  keeping  the  bladder  practically  clean 
and  in  protecting  the  kidney  from  any  important  dilatation  or  infection 
for  as  much  as  ten  or  twenty  years. 

One  can  scarcely  hope  to  cure  retention  of  urine  due  to  paralysis  of 
the  bladder  by  operation.  Yet  if  there  is  a  considerable  prostatic  en- 
largement it  may  be  worth  while  to  remove  this,  both  in  order  to  make 

^Boston  Med.  cf  Surg.  Jour.,  1910,  clxiii,  933,  995;  and  1911,  clxiv,  13. 


HERNIA  OF  THE  BLADDER  471 

catheterization  safer,  and  in  the  hope  that  the  retention  mav  actually 
be  relieved.  In  such  instances,  however,  one  must  not  forget  the  possi- 
bility of  exchanging  an  unpleasant  retention  for  an  unbearable  incon- 
tinence. ''Better  be  a  catheter  man  than  a  bag  man/'  as  a  wise  old 
gentleman  once  said  to  me. 

The  reported  operative  cures  may  be  taken  with  a  grain  of  salt. 
I  have  reported  some  myself.  But  if  stricture  or  prostate  call  for  opera- 
tion, an  intelligent  opening  up  of  the  bladder  neck  may  really  have  excel- 
lent results  in  relieving  some  of  the  patient's  symptoms,  even  to  the 
point  of  emptying  his  bladder. 


HERNIA  OF  THE  BLADDER   (CYSTOCELE) 

Cystocele  is  scarcely  recognizable  except  during  herniotomy,  and  its 
whole  clinical  interest  centers  on  the  diagnosis  of  the  condition  before 
the  bladder  is  injured  by  the  knife,  and  on  its  remedies  in  case  it  is  so 
injured. 

Abdominal,  inguinal  (scrotal,  sometimes  on  both  sides),  crural,  peri- 
neal, and  ischiatic  cystocele,  and  cystocele  through  the  foramen  ovale 
have  been  noted.  In  women  vaginal  cystocele  and  femoral  cystocele  are 
most  common ;  in  men,  inguinal.  Thus,  among  22  femoral  cystoceles 
collected  by  Gibson,^  16  occurred  in  women,  while  70  among  his  77 
cases  of  ingaiinal  cystocele  occurred  in  men.  Lotheissen  ^  collected  113 
cases  of  ingaiinal  cystocele  in  men  and  only  11  in  women.  He  believes 
that  cystocele  occurs  in  3  per  cent  of  all  inguinal  herniae,  although  the 
usual  estimate  is  from  1  to  2  per  cent.  Ingiiinal  cystocele  is  extra- 
peritoneal in  69.2  per  cent  of  cases,  paraperitoneal  ("mixed")  in  24.2 
per  cent,  and  intraperitoneal  in  only  Q.Q  per  cent.  As  extraperitoneal 
cystocele  is  met  with  only  in  direct  ingiiinal  herniae,  it  is  in  this  class 
of  cases  that  cystocele  is  to  be  looked  for. 

Cystocele  is  especially  common  between  the  ages  of  thirty  and  sixty. 
Its  pathogenesis,  depending  partly  upon  the  hernial  traction,  partly 
upon  dilatation  of  the  bladder,  has  been  studied  by  Lotheissen,  Lam- 
bret,^  Cheesman,*  and  Alessandri." 

Diagnosis — The  diagnosis  is  rarely  made  before  operation.  The 
suspected  presence  of  cystocele  is  verified  by  the  introduction  of  a  sound 
into  the  bladder. 

Treatment — The  proper  treatment  of  cystocele  is  herniotomy.     If 

^Med.  liecord,  1897,  li,  401. 

'Briins  Beitriige,  1898,  xx.  727. 

'Bull,  med'.,  1899,  xiii,  i,  397. 

*Med.  Eecord,  1001,  lix.  985. 

^Guyon's  Annales,  1901,  xix,  25,  153,  and  325. 


472        PHYSIOLOGY  AND  VARIOUS  DISEASES  OF  BLADDER 

the  cystocele  is  extraperitoneal,  it  may  not  be  easy  to  close  the  abdominal 
wall  firmly  over  it.  Unintentional  incision  of  the  bladder  during  herni- 
otomy is  rather  a  grave  complication.  Lotheissen  collected  65  such  cases 
with  18  deaths.  The  bladder  should  be  closed  by  two  layers  of  Lem- 
bert  sutures,  the  efficacy  of  the  line  of  suture  tested  by  the  intravesical 
injection,  and  the  radical  cure  completed.  At  the  end  of  the  operation 
a  catheter  should  be  tied  into  the  urethra.  If  the  patient's  condition 
does  not  warrant  the  delay  necessary  to  accomplish  a  satisfactory  suture 
of  the  bladder,  the  organ  may  be  fixed  in  the  external  wound  and  per- 
mitted to  heal  after  the  manner  of  a  suprapubic  cystotomy  wound. 


INTESTINAL  FISTULA 

Vesico-intestinal  fistula  may  be  traumatic,  ulcerative,  cancerous, 
tuberculous,  or  congenital.  Congenital  fistula  is  extremely  rare.  jN'inety- 
five  reported  cases  of  acquired  vesico-intestinal  fistula  in  man  have  been 
collected  by  Chavannaz.^  Of  these,  13  were  traumatic,  29  ulcerative 
(from  stone,  abscess,  etc.),  19  cancerous,  7  tuberculous,  and  27  unclassi- 
fied. The  fistula  usually  opens  into  the  rectum  (43  cases)  or  into  the 
sigmoid  flexure  (14  cases),  but  it  may  open  into  almost  any  part  of  the 
intestine,  even  the  appendix  vermiformis  (as  a  result  of  the  bursting 
of  an  appendicular  abscess).  The  fistula  may  be  short  and  direct,  but 
in  fully  25  per  cent  of  the  cases  there  is  an  intermediate  suppurating 
cavity  between  the  vesical  and  the  intestinal  orifice. 

Symptoms. — The  most  notable  symptom  of  vesico-intestinal  fistula 
is  the  passage  of  gas  from  the  urethra  (pneumaturia) .  This  symptom 
is  always  present  and  is  always  noted  by  the  patient.  The  urine  may 
also  be  passed  partly  or  wholly  by  the  bowel,  and,  when  the  opening  is 
large,  feces  may  enter  the  bladder  and  issue  with  the  urine.  Cystitis  is 
inevitable. 

Diagnosis. — As  a  rule,  the  diagnosis  may  be  made  from  the  presence 
of  pneumaturia,  although  gas  may  be  evolved  by  fermentation  within 
the  bladder  itself.  Thus  the  intravesical  action  of  the  yeast  fungTis 
upon  saccharine  urine  has  been  known  to  cause  pneumaturia,  and  I  have 
seen  two  obscure  cases  in  which  the  presence  of  gas  could  not  be  ac- 
counted for.  If  the  evidences  of  bladder  disease  do  not  sufficiently  con- 
firm the  diagnosis  of  fistula,  an  injection  of  methylene-blue  solution  into 
the  bladder  will  decide  the  question  by  transuding  through  the  fistula 
and  appearing  in  the  dejecta.  The  position  of  the  fistula  may  be  esti- 
mated by  cystoscopy,  by  rectal  touch,  or  by  the  rectal  speculum. 

*Cf.  Parham  and  Hume  (Ann.  Surg.,  1909,  1,  251),  who  have  collected  385  cases; 
also  Minakuchi  (Beitr.  z.  Geburts.  u.  Gynec,  1913,  xvii,  No.  3),  who  enumerates  45 
cases,  27  of  them  due  to  obstetrical  and  operative  injury. 


INTESTINAL  FISTULA  473 

Prognosis.- — The  prognosis  depends  on  the  nature  of  the  fistula. 
Traumatic  fistulae  often  heal  spontaneously  if  the  bladder  is  kept  clean 
and  the  urethra  clear.    Tuberculous  and  malignant  fistulae  will  not  heal. 

Treatment. — Palliative  treatment  consists  of  daily  irrigation  of 
bladder  and  bowel.  Colostomy  is  the  only  appropriate  treatment  for 
incurable  fisfula.  Temporary  colostomy  is  also  employed  as  a  pre- 
liminary to  the  attempt  at  radical  cure. 

A  radical  cure  may  be  attempted  in  several  ways.  Chavannaz  re- 
ports three  cures  by  dilating  the  fistula  and  scraping  its  rectal  extremity. 
Separation  of  the  viscera  through  a  laparotomy,  and  excision  of  the 
fistula  with  suture  of  its  orifice  is  the  proper  radical  operation. 


CHAPTER   XLIX 

DISEASES  PECULIAR  TO  THE  FEMALE  BLADDER 

Many  of  the  conditions  peculiar  to  the  female  bladder  require  no 
special  mention  here,  or  are  sufficiently  dealt  with  elsewhere  in  this 
work.  Thus,  for  example,  the  bladder  very  rarely  becomes  tuberculous 
as  a  result  of  invasion  from  the  fallopian  tube.  Acute  infection  of 
the  uterine  adnexa  may  involve  and  rupture  into  the  bladder.  Adhe- 
sions may  cause  irritation  and  even  cystitis  by  pulling  upon  the  bladder, 
and  the  fibroid  uterus  may  cause  similar  results.  The  pregnant  woman 
often  suffers  a  temporary  bladder  irritation  and  cystitis.  The  so-called 
puerperal  pyelitis  is  a  usually  descending  infection. 

But  certain  features  of  the  pathology  of  the  female  bladder  require 
a  rather  more  detailed  mention. 

CYSTOSCOPIC    PECULIARITIES    OF    THE   FEMALE    BLADDER 

Although  cystocele  may  occur  in  the  virgin,  as  a  general  rule  the 
bladder  of  the  woman  who  has  not  borne  children  presents  a  cystoscopic 
picture  not  very  different  from  that  of  the  young  male.  If  anything, 
the  trigonal  landmarks  are  not  so  clearly  and  distinctly  marked,  so 
that  the  ureters  are  harder  to  find. 

But  the  multipara  usually  loses  practically  all  the  trigonal  markings. 
The  ureters  are  found  only  by  a  knowledge  of  where  they  should  be 
looked  for.  There  is  no  interureteric  ridge  or  lateral  edge  of  the  trigone 
sufficiently  marked  to  lead  the  eye  to  them. 

This  absence  of  trigonal  markings  is  most  commonly  seen  in  cases 
of  cystocele.  The  amount  of  cystocele  may  be  measured,  not  only 
by  the  bulging  to  be  seen  in  the  vagina,  but  also  by  the  amount  of 
residual  urine,  as  well  as  by  the  angle  to  which  the  cystoscope  must 
be  brought  in  order  to  approximate  its  lens  to  the  ureteral  orifices. 
These  will  usually  be  found  much  nearer  the  urethra  than  the  inexpert 
cystoscopist  expects  to  find  them. 

Marked  cystocele  causes  retention  of  urine  and  symptoms  in  the 
female  similar  to  mild  prostatism  in  the  male. 

Marked  anteflexion  of  the  uterus  and  tumors  on  the  anterior  uterine 
wall  as  well  as  other  pelvic  tumors  and  adhesions  may  depress  and 

474 


CYSTOSCOPIC  PECULIARITIES  475 

distort  certain  portions  of  the  bladder  wall  (PI.  I).  Pregnancy  has 
a  similar  effect. 

Carcinoma  of  the  Cervix. — When  a  carcinoma  of  the  cervix  uteri 
invades  the  anterior  or  lateral  vaginal  walls,  the  most  accurate  means 
of  ascertaining  the  condition  of  the  vesicovaginal  septum  is  by  means 
of  the  cystoscopic  examination.  The  cystoscopic  examination  becomes 
progressively  more  important  as  the  gTowth  extends,  and  the  nearer  it 
approaches  the  borderland  between  operative  and  nonoperative. 

"When  the  carcinoma  approaches  and  invades  the  vesicovaginal  sep- 
tum it  interferes  with  the  blood  supply  of  the  bladder,  particularly 
in  those  portions  supplied  by  the  middle  and  inferior  vesical  vessels. 
And  cystoscopically  we  have  bladder  pictures  of  all  grades  of  venous 
stasis  (PL  I). 

A  number  of  these  bladder  alterations  are  similar  to  those  occurring 
with  vesical  or  perivesical  inflammations,  and  care  must  be  taken  in 
distinguishing  between  the  two.  The  differentiation  can,  however,  prac- 
tically always  be  made. 

The  cystoscopic  examination  includes : 

A.  Estimation  of  the  direction  of  the  urethra  and  the  position  of 
the  trigone,  marked  elevation  of  the  trigone  meaning  inoperable  car- 
cinoma. 

B.  Conditions  within  the  bladder: 

1.  Tumor  masses  encroaching  upon  or  causing  retraction  of  the 

bladder. 

2.  The  alterations  of  the  bladder  which  are  similar  to  those 

occurring  with  vesical  or  paravesical  inflammations. 
These  are  (a)  folding  and  swelling  of  the  bladder  mu- 
cous membrane,  (6)  varicosities  of  the  bladder  vessels, 
,  (c)  submucous  hemorrhages,  (d)  congestion  of  the  blad- 
der, (e)  cystitis,  (/)  bullous  edema.  The  most  important 
among  these  conditions  within  the  bladder  which  indicate 
involvement  of  the  vesicovaginal  septum  are :  Tumor 
masses  encroaching  upon  or  causing  retraction  of  the 
bladder;  folding  and  swelling  of  the  bladder  mucous 
membrane;  marked  varicosities. 
Bladder   Neuroses. — Bladder  neuroses  can  be  divided  into  three 

classes :  First,  those  due  to  a  definite  nerve  lesion,  e.  g.,  tabes  dorsalis. 

Second,  those  in  which  the  nerve  lesion  is  not  definitely  known — as  when 

we  have  bladder  disturbances  in  a  neurasthenic  or  hysterical  patient. 

Third,  those  in  which  the  bladder  disturbance  is  a  reflex,  as  in  a  rectal 

fissure  or  disease  of  the  pelvic  organs. 

These  conditions  are  seen  alike  in  men  and  women.     The  general 

symptomatology  of  bladder  neuroses  is  classified  by  von  Frank  1-Iioch- 

wart  as  follows : 


476  DISEASES  PECULIAR  TO  THE  FEMALE  BLADDER 

1.  The  Sensory  anomalies. 

A.  Pain. 

B.  Anomalies  of  ■urination. 
a.  Increase. 

h.  Decrease. 

2.  Dysuria. 

3.  Urinary  Retention. 

4.  Incontinence. 

Paiist. — The  cause  of  painful  and  frequent  urination  is  more  often 
obscure  in  women  than  in  men.  Nevertheless,  it  always  has  a  cause, 
and  this  cause  should  be  disclosed  by  a  careful  examination.  The  physi- 
cal examination  should  include  an  investigation  both  of  the  kidneys 
and  of  the  pelvic  organs  for  palpable  displacement,  adhesions,  tumors, 
enlargement,  inflammation,  etc.,  which  may,  either  by  infection  or 
by  mechanical  means,  cause  irritation  of  the  bladder.  If  no  such  causes 
of  the  disturbance  are  found,  one  has  recourse  to  cystoscopy,  urethros- 
copy, and  urinalysis.  Thus  we  may,  in  a  good  many  cases,  readily 
rule  out  the  usual  stone,  tumor,  inflammation,  tuberculosis,  etc.,  which 
are  common  to  male  and  female  and  give  gross  and  readily  recognizable 
lesions  in  most  cases.  There  still  remain  cases  of  bladder  pain  and 
frequent  urination  to  be  accounted  for.  Many  of  these  will  be  found 
to  have  a  very  slight  infection  dependent  upon  a  mild  pyelonephritis 
and  curable  by  lavage  of  the  kidney  pelvis  with  silver  nitrate  or  by 
improving  the  patient's  general  health.  Others  will  be  found  to  have 
mild  degrees  of  cystocele  and  other  slight  displacements  improvable 
by  mechanical  or  operative  means.  Others  still  have  obscure  inflam- 
mations of  the  bladder  which  are  of  two  types : 

1.  Ulcerative  cystitis,  which  may  be  the  simple  ulcer  of  the  vault 
described  by  Hunner  or  the  diffused  aphthous  staphylococcus  cystitis 
with  little  intervening  general  inflammation,  or  leukoplakia,  or  cystitis 
cystica. 

2.  Trigonitis,  due  to  the  extension  of  urethritis  to  the  adjacent 
portion  of  the  bladder  base,  is  a  diagnosis  upon  which  the  unskilled 
cystoscopist  relies  too  often  to  explain  a  condition  for  which  he  can 
find  no  other  cause.  The  diagnosis  of  trigonitis  should  only  be  made 
when  the  trigone  is  actually  seen  to  be  inflamed.  The  trigonitis  may 
descend  from  the  kidneys,  or  ascend  from  the  urethra.  If  the  kidneys 
are  uninfected  (as  disclosed  by  culture  of  the  urine)  the  trigonitis 
may  be  looked  upon  as  of  urethral  origin,  and  a  cure  may  be  expected 
by  treatment  of  the  urethra,  either  by  dilatation  by  sounds  or  by  the 
application  of  1  per  cent  silver  nitrate  solution,  or  2  per  cent  carbolic 
acid,  or  20  per  cent  argyrol. 

Reteiv^tion  and  Incontinence  of  Urine. — Retention  is  only  in- 
teresting because  it  is  so  rarely  looked  for  and  hence  so  frequently 


CYSTOSCOPIC  PECULIARITIES  477 

overlooked.  Its  results  are  quite  the  same  in  women  as  in  men.  It 
can  usually  be  cured  by  dilating  the  urethra  or  by  plastic  operation 
for  the  relief  of  cystocele. 

Incontinence  of  urine  is  a  much  more  difficult  topic  in  women,  be- 
cause the  normal  woman  has  so  slight  a  hold  upon  her  bladder  sphincter. 
Many  women  not  obviously  diseased  lose  control  of  their  bladder  sphinc- 
ter to  a  certain  extent  through  such  slight  causes  as  catching  cold  or 
diarrhea.  Incontinence  is,  of  course,  often  a  symptom  of  overflow  in 
women  as  it  is  in  men,  and  retention  should  always  be  carefully  ex- 
cluded in  these  cases. 

Finally,  there  is  a  class  of  operative  cases  in  which  the  sphincteric 
relaxation  is  due  to  pregnancy  or  to  surgical  operations.  Kelly  ^  has 
reviewed  the  treatment  of  this  condition  and  advises  for  its  operative 
relief  a  median  vertical  incision  made  in  the  anterior  vaginal  wall  over 
a  Pezzer  catheter  in  the  bladder  to  identify  the  position  of  the  bladder 
neck.  The  vaginal  wall  is  carefully  dissected  free  until  the  finger  can 
gTasp  at  least  one-half  or  two-thirds  of  the  neck  of  the  bladder  including 
the  contiguous  urethra.  Two  or  three  lateral  mattress  sutures  of  fine 
silk  or  linen  are  then  used  to  approximate  the  tissues  on  each  side 
of  the  vesical  neck.  The  first  one  takes  in  about  1.5  cm.  of  tissue, 
the  next  takes  in  another  fold  over  this  one.  The  catheter  is  removed, 
the  superfluous  vaginal  mucosa  resected,  and  the  incision  sutured  in 
several  layers  with  fine  catgut.  A  perineorrhaphy  may  be  done  at  the 
same  time.  Postoperative  catheterization  is  avoided  as  far  as  possible. 
Kelly  reports  16  successful  operations. 

*  Surg.,  Gyn.  4"  Obstet.,  April,  1914,  xviii,  444. 


CHAPTER   L 

IDIOPATHIC  RENAL  HEMATURIA— VARICOSE  VEINS  OF  THE 

BLADDER 

IDIOPATHIC   OR  ESSENTIAL  RENAL  HEMATURIA 

The  hematuria  that  occurs  with  tumor  of  the  kidney  is  at  once  the 
most  important  and  the  most  profuse  spontaneous  hemorrhage  from  that 
organ.  Bleeding  is  also  a  common  symptom  of  renal  stone  and  tuber- 
culosis; and  when  the  kidney  bleeds,  one  of  these  three  conditions — 
stone,  tubercle,  or  tumor — is  usually  suspected.  But  there  are  a  great 
many  other  diseases,  a  few  of  them  surgical  in  their  aspects  and  most  of 
them  medical,  in  which  renal  hemorrhage — even  profuse  renal  hemor- 
rhage— may  occur.  To  such  profuse  hemorrhage  from  an  obscure  cause 
has  been  given  the  name  of  essential  or  idiopathic  renal  hematuria. 

Etiology. — The  causes  to  which  this  essential  renal  hematuria  has 
been  attributed  may  be  classified  as  follows: 

1.  Hemophilia,   scurvy,   purpura. 

2.  Drug-poisoning  (turpentine,  cantharides,  etc.). 

3.  Parasites  (e.  g.,  distoma  hematobium). 

4.  Acute  or  chronic  febrile  diseases  (scarlet  fever,  malaria). 

5.  Surgical  diseases   (hydronephrosis,  renal  mobility). 

6.  The  passage  of  crystals. 

7.  Angioneurosis. 

8.  Chronic  nephritis. 

9.  Papillitis. 

It  is  not  necessary  to  consider  all  these  conditions  in  detail.  Dis- 
toma, for  instance,  is  practically  never  heard  of  in  these  latitudes. 
Renal  hemorrhage  caused  by  drugs  or  occurring  in  the  course  of  one  of 
the  bleeding  diseases  has  no  surgical  interest.  There  remain  the  hema- 
turia due  to  surgical  causes,  to  angioneurosis,  to  chronic  nephritis,  and 
to  papillary  varicosities.  It  is  possible  that  any  of  these  causes  may 
produce  a  profuse  renal  hemorrhage.  Ureter  catheterization,  pyelog- 
raphy and  examination  of  the  loin  should  eliminate  hydronephrosis  and 
movable  kidney,  and  there  are  left  for  our  consideration  only  angioneu- 
rosis, chronic  nephritis,  and  papillary  varicosity. 

That  hematuria  may  be  due  to  chronic  nephritis  requires  no  proof. 
iExamples  are  commonplace.     But  such  examples,  representing  a  hem- 

178 


IDIOPATHIC  OR  ESSENTIAL  RENAL  HEMATURIA  479 

orrhage — even  a  profuse  liemorrliage  or  a  series  of  such — in  the  course 
of  an  acute  or  active  nephritis  have  no  peculiar  surgical  interest. 

What  we  need  to  know  is  whether  a  prolonged,  profuse  hemorrhage 
may  result  from  chronic  nephritis  in  the  absence  of  any  other  sign  of 
this  inflammation. 

Up  to  1895,  or  thereabouts,  the  question  was  answered  mainly  in  the 
negative.  Otherwise  inexplicable  profuse  or  persistent  hematuria  was 
attributed  to  angioneurosis.  But  in  the  following  decade  many  nephrec- 
tomies performed  for  this  condition  revealed,  almost  constantly,  either 
parenchymatous  or  interstitial  nephritis,  which  had  given  no  symptoms 
or  urinary  signs  other  than  the  bleeding.  In  spite  of  the  fact  that  the 
bleeding  point  was  not  found,  the  so-called  idiopathic  hematuria  was 
therefore  attributed  to  nephritis. 

But  as  early  as  1898  the  bleeding  point  was  found  in  three  cases  to 
be  due  to  oozing  from  varicose  veins  of  a  renal  papilla.  Fenwick  -^  re- 
ported six  such  cases,  Hugh  Cabot  ^  added  another,  and  subsequent 
observers  have  added  others,  preferring  to  attribute  the  condition  to 
inflammation  under  the  title  "Papillitis."  The  affected  papilla  bleeds 
and  looks  purple  and  "spongy."     Section  demonstrates  the  varicosities. 

Papillitis  explains  many  but  not  all  cases.  A  few  still  remain  abso- 
lutely unexplained  (cf.  Schwyzer^). 

Symptoms. — There  is  but  one  symptom — viz.,  profuse  hematuria. 
This  may  be  constant  or  intermittent.  It  is  rarely  sufficiently  severe  to 
cause   anemia. 

The  bleeding  may  last  a  few  hours  or  it  may  continue  for  days ;  hav- 
ing once  occurred  it  may  never  appear  again ;  or  it  may  return  time  after 
time,  and  be  so  profuse  as  to  threaten  the  patient's  life.  In  the  pres- 
ence of  a  condition  so  various  in  its  manifestations,  so  comparable  in 
its  only  symptom  to  carcinoma  of  the  kidney,  so  dangerous  in  its  con- 
tinuance, a  diagnosis  is  of  the  utmost  importance,  and  a  diagnosis  is 
difficult  to  obtain.  Full  realization  of  the  fact  that  the  bleeding,  which 
is  so  often  the  first  symptom  of  malignant  growth  in  the  kidney,  may 
occur  two,  three,  or  even  five  years  before  any  other  symptom,  cannot 
fail  to  impress  upon  the  surgeon  the  necessity  for  the  utmost  caution 
in  deciding  the  nature  of  the  malady.  It  is  not  sufficient  that  the 
hemorrhage  cease.  This  it  does  spontaneously.  The  patient  should 
be  warned  that  his  bleeding  may  be  the  first  symptom  of  serious  renal 
disease  and  a  careful  examination  insisted  upon. 

The  surgeon  must  recognize  that  the  more  spontaneous  the  bleeding 
and  the  more  entirely  free  the  patient  from  any  other  symptom,  the 
greater  is  the  probability  of  malignant  disease. 

*" Clinical  Cystoscopy,"  London,  1904. 

^  Trans.  Am.  Assn.  Gen.-Urin.  Surgeons,  1908,  iii. 

^Ann.  Surg.,  1909,  xlix,  628. 


480  VARICOSE  VEINS  OP  THE  BLADDER 

Diagnosis. — Renal  tumor  and  idiopatliic  hematuria  may  usually  be 
readily  distinguished  by  palpation  of  a  loin  tumor  and  ureter  catheteri- 
zation, revealing  a  deficient  function  in  the  case  of  tumor.  If  these  fail 
pyelography  reveals  deformity  of  the  kidney  by  tumor.  If  the  examina- 
tion fails  to  show  chronic  nephritis,  stone,  tuberculosis  or  tumor,  the 
diagnosis  of  papillitis  or  essential  hematuria  is  made  by  exclusion. 

Treatment. — Idiopathic  renal  hemorrhage  may  often  be  checked  by 
the  administration  of  0.5  gram  of  turpentine  in  capsules  three  times  a 
day.  By  this  treatment  I  have  been  able  to  cure  some  five  or  six  cases. 
In  one  striking  case  the  patient  had  been  bleeding  profusely  for  a  month. 
Every  drop  of  urine  passed  v^as  stained  dark  red  by  the  contained 
blood.  One  v^eek  on  turpentine  sufficed  to  check  the  bleeding  absolutely 
and  permanently.  Yet  in  another  case  the  bleeding  was  checked  by 
turpentine,  recurred  several  years  later,  and  was  then  not  amenable  to 
that  drug,  nor  would  the  patient  accept  operative  exploration. 

Hagner  ^  has  checked  several  cases  (notably  one  of  constant  bleeding 
for  thirty-six  years)  by  passing  the  ureter  catheter.  Others  have 
achieved  a  like  result  by  injection  of  adrenalin  into  the  renal  pelvis. 

In  case  such  methods  fail,  nephrotomy  should  be  performed  and  the 
bleeding  papilla  curetted.  If  the  papilla  is  not  found,  nephrotomy  (or 
even  decapsulation)  may  still  cure.     Nephrectomy  is  the  last  resource. 

Braasch  ^  reports  11  cases.  In  26  cases  ureter  catheterization 
checked  the  bleeding  (4  relapses)  ;  in  18  pelvic  lavage  succeeded  (3 
relapses)  ;  6  were  checked  by  adrenalin  injection  (5  relapses).  !N^e- 
phrotomy  was  performed  12  times  with  1  cures.  ISTephrectomy  was 
performed  16  times  with  one  death. 


VARICOSE  VEINS  OF  THE  BLADDER 

A  few  cases  have  been  reported  which  showed  only  one  symptom — 
i.  e.,  a  spontaneous,  profuse,  uncontrollable  hemorrhage  of  the  bladder, 
which  hemorrhage  was  found  to  arise  from  a  ruptured  varicose  vein 
lying  immediately  under  the  mucous  membrane.  The  diagnosis  was 
made  either  by  cystoscopy  as  the  hemorrhage  was  ceasing,  or  by  supra- 
pubic cystotomy  undertaken  for  the  relief  of  the  hemorrhage.  If  the 
hemorrhage  does  not  stop  spontaneously  the  only  treatment  is  cystotomy 
with  ligature  or  cauterization  of  the  bleeding  point. 

I  have  several  times  seen  varicose  veins  in  the  bladder  (PI.  I), 
but  have  never  known  them  to  bleed. 

*  Trans.  Am.  TJrolog.  Assn.,  1907,  i. 
""Jour.  A.  M.  A.,  June  1,  1913. 


CHAPTEK   LI 

CYSTS  AND  TUMORS  OF  THE  KIDNEY 

CYSTS 

Seven  varieties  of  cysts  occur  in  and  about  the  kidney.    These  are : 

1.  Multiple  small  cysts. 

2.  Paranephritic  cysts. 

3.  Large  simple  cysts. 

4.  Tuberculous  cysts. 

5.  Cystic  degeneration. 

6.  Echinococcus  cysts. 

7.  Dermoid  cysts. 

1.  Multiple  Small  Cysts. — Multiple  small  cysts  are  those  dilata- 
tions of  the  renal  tubules  that  are  often  seen  in  kidneys  affected  with 
chronic  nephritis.  They  usually  occur  in  the  cortex  and  often  project 
beneath  the  capsule.  They  may  be  single  or  multiple ;  they  do  not  seem 
to  attain  a  large  size  and  are  of  purely  pathological  interest. 

2.  Paranephritic  Cysts — Paranephritic  cysts  also  may  be  dismissed 
with  a  word.  They  are  extremely  rare;  they  may  arise  from  the 
suprarenal  capsule;  they  may  be  hydatid  or  the  result  of  an  encysted 
perinephritic  hematoma.  They  are  not  distinguishable  from  other 
cysts  of  the  kidney  except  by  exploratory  incision.  Morris  ^  has  col- 
lected their  published  records. 

3.  Simple  Cysts  of  the  Kidney. — Single,  large  serous  cysts  are  oc- 
casionally found  projecting  from  the  surface  of  the  kidney.  Such  cysts 
may  be  single  or  multiple.  They  may  be  associated  with  chronic  in- 
terstitial nephritis;  they  are  rarely  bilateral.  The  contents  of  the 
cysts  are  serous  or  hemorrhagic,  never  urinous.  Such  cysts  give  rise  to 
no  symptoms  unless  they  attain  such  a  size  as  to  produce  a  tumor  or 
to  cause  pressure  pain,  Undet  these  circumstances  the  tumor  is  habit- 
ually mistaken  for  hydronephrosis,  renal  echinococcus,  ovarian  cyst, 
or  some  other  tumor.  Exploratory  incision  reveals  the  nature  of  the 
disease.  The  proper  treatment  of  such  cysts  is  to  excise  them  with  the 
adjacent  portions  of  the  renal  tissue,  or,  if  this  is  impracticable,  to 
cut  away  as  much  of  the  cyst  as  possible,  to  sear  the  surface  of  the 
remainder  with  carbolic  acid,  and  to  close  the  lumbar  wound,  leaving 

** 'Surgery  of  the  Kidneys." 

481- 


482 


CYSTS  AND  TUMORS  OF  THE  KIDNEY 


a  drainage-tube  to  the  kidney.  When  the  cysts  are  multiple  Morris 
advises  that  the  smaller  ones  be  neglected.  Englander  ^  has  reviewed 
the  reported  cases  from  the  surgical  point  of  view. 

4.  Tuberculous  Cysts. — Large  cysts  are  infrequently  seen  in  renal 
tuberculosis.     They  have  no  clinical  interest. 

5.  Cystic  Degeneration  of  the  Kidney  (Large  Polycystic  Kidney). 
— The  kidney  is  converted  into  a  congeries  of  cysts  which  leave  scarcely 
any  of  its  parenchyma  in  a  normal  condition  (Fig.  99).     The  patho- 

,__„-^ ,  genesis  of  this  condi- 

tion is  hotly  debated. 
The  three  favorite  the- 
ories are : 

1.  That  the  cysts 
are  incidental  to  a 
chronic  interstitial  ne- 
phritis. This  explains 
the  bilateral  nature  of 
the  disease,  but  does 
not  show  why  it  should 
be  associated  with  a 
similar  cystic  condi- 
tion in  other  organs, 
notably  the  liver. 

2.  That  they  are 
the  result  of  congenital 
malformation  in  that 
the  kidney  pelvis  does 
not  become  properly 
apposed  to  the  paren- 
chyma. 

3.  That  they  are 
cystadenomata. 

So  much  for  the 
theories.  From  the 
clinician's  point  of 
view  the  facts,  though  definite  enough,  are  equally  confusing.  The 
disease  appears  at  all  ages.  In  the  fetus  the  kidneys  have  been  known 
to  be  so  much  enlarged  as  to  obstruct  labor.  Certain  writers  have 
endeavored  to  distinguish  congenital  cystic  degeneration  from  that 
which  occurs  in  adults,  but  there  is  no  foundation  for  this  distinc- 
tion. The  condition  is  always  bilateral.  Among  62  cases  collected  by 
Lejars  only  1  was  unilateral,  and  even  in  that  one  there  was  a 
single  small  cyst  in  the  opposite  kidney  (Morris).    Another  peculiarity 

^Archiv  f.  Min.  Chir.,  1901,  Ixv,  112. 


Fig.  99. — Polycystic  Kidney. 


CYSTS 


483 


of  the  disease  is  the  frequency  with  which  the  liver  is  involved.  Of 
Ritchie's  88  cases  86  were  bilateral,  the  liver  was  cystic  in  21,  and  the 
thyroid  gland,  the  uterus,  and  the  ovary  each  cystic  in  one  case. 

Pathology. — The  most  striking  feature  of  the  fully  developed 
cystic  kidney  is  its  size.  The  organ  grows  so  large  as  to  fill  the  entire 
lumbar  region  and  to  project  anteriorly  almost  to  the  median  line  (Fig. 
100).  The  disease  usually  progresses  more  rapidly  upon  one  side  than 
upon  the  other,  so  that  one  kidney  may  be  so  much  enlarged  as  to  form 
a  visible  abdominal  tumor,  while  the  other  can  not  be  palpated.  The 
largest  recorded  specimen  weighed  16  pounds    (Hare). 

Apart  from  its  size,  the  most  strikino;  characteristic  of  this  growth 


Fig.  100. — Outline  of  Polycystic  Kidney  and  Spleen.     Duration  8  years;  death  six 
months  later.     Right  kidney  and  liver  also  involved. 


is  its  irregularity  of  surface.  When  the  kidney  has  grown  to  such  a 
size  as  to  cause  a  surface  tumor  palpation  reveals  the  existence  over 
the  growth  of  larger  or  smaller  rounded  lumps,  some  hard,  some  elastic, 
and  some  even  fluctuating.  This  characteristic  irregularity  of  surface 
is  all  but  pathognomonic  of  cystic  disease  of  the  kidney. 

On  section  the  cystic  kidney  shows  an  infinite  number  of  cysts  of 
varying  sizes.  With  the  naked  eye  it  may  be  impossible  to  detect  any 
normal  renal  tissue.  The  contents  of  the  cysts  are  liquid,  viscid,  col- 
loid, or  caseous.  They  are  usually  amber-colored,  rarely  dark  and  hem- 
orrhagic, and  exceptionally  suppurating.  The  cyst  contents  are  not 
urinous,  and  the  cysts  do  not  communicate  with  the  sinus  of  the  kidney. 
Exceptionally  calculi  are  found  in  the  cysts,  and  in  tlie  kidney  pelvis. 

SYMPTo:\rs. — The  symptoms  of  the  disease  are  habitually  those  of 
chronic  interstitial  nephritis,  and,  unless  the  tumor  grows  tosucli  a  size 


484  CYSTS  AND  TUMORS  OP  THE  KIDNEY" 

as  to  attract  attention,  tlie  disease  runs  its  course  and  terminates  as 
chronic  nephritis.  The  urine  is  albuminous  and  contains  casts.  There 
is  polyuria. 

The  surgical  symptoms  are  hematuria,  which  occurs  in  25  per  cent 
of  all  cases  (Newman  ^),  tumor,  and  pain.  Pyuria  from  secondary  in- 
fection is  occasionally  associated  with  calculus. 

The  course  of  the  disease  is  slow.  Morris  estimates  the  expectation 
of  life  at  from  one  to  ten  years,  although  Ritchie  has  recorded  a  case 
living  twenty-two  years  after  the  diagnosis  had  been  made. 

Diagnosis. — So  rarely  does  the  renal  condition  attract  attention 
that  only  5  of  Le jar's  62  cases  were  correctly  diagnosed  during  life. 
According  to  Morris,  the  tumor  is  discovered  during  life  in  25  per  cent 
of  cases,  and  about  50  per  cent  complain  of  symptoms  closely  resembling 
those  of  chronic  interstitial  nephritis.  When  there  are  hemorrhage, 
pain,  or  pyuria  and  slight  enlargement  of  the  kidney  this  is  likely  to 
be  mistaken  for  one  of  the  surgical  diseases  of  that  organ. 

The  diagnosis  can  usually  be  made  by  palpation.  (I  was  once 
misled  by  a  symptomless  bilateral  calculous  hydronephrosis.  The  pa- 
tient dropped  dead  the  next  day. )  In  one  of  my  cases  radiography  dis- 
closed the  cystic  nature  of  two  moderately  enlarged  kidneys.  (The 
patient  insisted  upon  pyelography,  which  I  refused.  It  was  done  by 
another  surgeon  and  caused  such  alarming  symptoms  that  nephrectomy 
was  immediately  performed.)  Braasch  states  that  "the  pelvic  outline 
of  bilateral  cystic  kidney  is  characterized  by  flattening  of  the  calices, 
giving  a  general  oval  contour  to  the  pelvis,  in  contradistinction  to  the 
retracted  calices  of  tumor.  Occasionally,  however,  a  retraction  of  the 
calices  may  also  be  found  with  the  bilateral  cystic  kidney,  but  it  then 
is  broad  and  open,  not  slit-like  or  narrow." 

Treatment. — Cystic  degeneration  of  the  kidney  is  not  a  surgical 
disease;  in  its  clinical  aspects  it  is  a  chronic  interstitial  nephritis. 

Eovsing  ^  has  had  some  success  in  temporarily  relieving  pain  and 
improving  kidney  function  in  3  cases  by  multiple  incision  and  punc- 
ture of  cysts  until  the  kidney  is  reduced  to  a  normal  size.  Lund  ^ 
reports  four  cases  of  improvement  following  this  operation. 

llTephrectomy  does  not  cure.  Its  immediate  mortality  is  very  high 
(33  per  cent  of  62  cases  reported  by  Sieber*). 

6.  Echinococcus  Cysts. — Echinococcus  cysts  of  the  kidney  are  rare. 
Houzel  ^  collected  the  statistics  of  Finsen  (Iceland),  Thomas  (Aus- 
tralia), IN^eisser,  and  Davaine,  a  total  of  2,111  cases  of  echinococcus 

^Glasgow  Med.  Jour.,  1897,  i,  324,  and  ii,  42. 

^Am.  Jour.  Urol.,  1912,  viii,  120. 

'Jour.  A.  M.  A.,  1914,  Ixiii,  1083. 

*Deutsch.  Zeitschr.  f.  Chir.,  1905,  Ixxix. 

''Bevue  de  chir.,  1898,  xviii,  689,  811.  Cf.  also  Carta-Mulas,  Gas.  d.  Osp.,  1915, 
xxxiv,  609. 


SOLID  TUMORS  OF  THE  KIDNEY  485 

cysts  in  men,  with  only  115(5  per  cent)  instances  of  renal  echinococcus. 

The  cyst  arises  in  the  cortex  of  the  kidney  and  grows  slowly,  with- 
out producing  symptoms,  until  it  reaches  such  a  size  as  to  form  an  ob- 
vious tumor,  or  ruptures.  When  left  to  itself  the  cyst  habitually  bursts 
into  the  pelvis  of  the  kidney,  and  its  contents  are  discharged  with  the 
urine.  This  occurs  in  52  of  the  63  cases  collected  by  Roberts.^  In 
3  of  these  cases  the  cyst  ruptured  into  the  intestines  as  well,  once  into 
the  stomach,  once  into  the  lungs;  and  of  the  11  remaining  cases  8  did 
not  rupture,  2  were  incised,  and  1  burst  into  the  lungs  only.  In  only 
18  of  these  cases  was  the  tumor  distinguished  during  life.  Suppuration 
of  the  cyst  may  occur  after  it  has  ruptured.  The  results  of  rupture  are 
not  necessarily  good.  The  cyst  may  for  years  continue  to  discharge 
without  ever  emptying  itself. 

The  symptoms  of  the  disease  are  lumbar  tumor,  growing  slowly, 
with  little  fever  or  pain,  and  no  constitutional  symptoms.  The  tumor 
itself  simulates  a  hydronephrosis,  and  the  hydatid  fremitus  can  rarely 
be  obtained.  Later  in  the  disease  rupture  of  the  cyst  is  betokened 
by  a  renal  colic  and  followed  by  the  discharge  of  hydatid  vesicles 
through  the  urethra. 

Treatment. — Twenty  of  Koberts's  cases  recovered  and  19  are 
known  to  have  died.  The  only  treatment  of  the  disease,  and  often  the 
only  means  of  making  a  diagnosis,  is  nephrotomy.  After  the  cyst  has 
been  incised  and  thoroughly  washed  out  a  cure  may  be  expected.  It  is 
scarcely  necessary  to  excise  the  entire  cyst,  and  in  a  number  of  cases 
nephrectomy  has  proved  fatal. 

7.  Dermoid  Cysts — Baldwin  ^  has  collected  seven  reported  cases 
of  renal  dermoid  cysts. 

SOLID  TUMORS  OF  THE  KIDNEY 

BENIGN  TUMORS 

Benign  tumors  of  the  kidney  are  extremely  rare.  The  commonest 
of  them  is  the  renal  "lipoma,"  the  benign  type  of  "hypernephroma." 
True  lipoma  and  fibroma  have  been  described. 

These  benign  growths  have  no  clinical  features.  They  do  not  give 
rise  to  any  symptoms  and  the  diagnosis  is  only  made  post  mortem. 
Their  sole  interest  lies  in  the  fact  that  most  of  them  are  liable  to 
malignant  degeneration. 

MALIGNANT  GROWTHS 

Frequency. — Nine  cases  of  primary  renal  tumor  were  recorded  in 
4,505   autopsies.      Secondary  deposits  were  found  in  the  kidneys  10 

^"Urinary  and  Eenal  Diseases,"  2d  Edit.,  Phila.,  1872,  p.  566. 
^Surg.,  Gyn.  cf  Obstet.,  1913,  p.  219. 


48G 


CYSTS  AND  TUMORS  OF  THE  KIDNEY 


times  in  126  eases  of  carcinoma,  and  10  times  in  69  cases  of  sarcoma. 
While  these  secondary  deposits  are  commonly  bilateral  the  primary 
malignant  disease  is  habitually  unilateral.^  Renal  grov^^ths  are  about 
equally  frequent  in  the  two  sexes  and  on  the  two  sides.  The  distribu- 
tion of  the  disease  throughout  life  is  rather  striking.  Xiister  has  tabu- 
lated 422  cases  as  follows : 

From  birth  to  5  years 128 

Six  to  10  years  . 41 

Forty  to  50  years .  125 

Over  50  years 128 

Thus  the  malignant  tumors  of  the  kidney  may  be  considered  clin-  / 
ically  as  the  tumors  of  childhood  and  those  of  adult  life.     In  child- 
hood they  are  most  common  from  birth  to  the  fifth  year,  exceptional 
after  the  tenth  year.     In  adults  they  occur  most  commonly  between  the 
forty-fifth  and  the  sixtieth- year. 

The  malignant  tumors  of  the  kidney  may  be  divided  pathologically 
as  well  as  clinically  into  two  age  gToups,  viz.,  the  embryomata  (Wilms's 
tumors)  of  childhood  and  a  variety  of  tumors,  chief  among  which  are 
the  so-called  "hypernephromata"  of  adult  life. 

Trauma  and  heredity  have  not  been  shown  to  influence  tumors  of 
the  kidney  while  nephritis,  suppuration  and  stone  are  accidental  and 
secondary  rather  than  primary.  (Though  epithelioma  secondary  to 
stone  has  been  noted.) 


TiJMOES 

C? 

ises 

Wilson 

71 

2 

7 
4 
1 

3 
1 
3 

92 

Watson 

"Hypernephroma"    

45 

Hypernephroma  of  the  adrenal 

Papillary   adenoma  "    

4 
4 

Papillary   cystadenoma  ^    

11 

Sarcoma    

2 

Carcinoma 

3 

Fibroma 

Lipoma    

Embryoma 

Epithelioma  of  the  pelvis 

Papilloma  of  the  pelvis 

Totals , 

14 
5 

1 
89 

^  Wagner  (Folia  Urol.,  1912,  vi,  619)  reports  a  case  with  primary  tumors  in 
each  kidney  and  quotes  Kiister's  statistics  which  showed  post  mortem  42  (out  of 
261)  cases  of  metastasis  of  a  renal  tumor  in  the  opposite  kidney. 

'should  doubtless  be  classed  with  "hypernephroma." 


SOLID  TUMORS  OF  THE  KIDNEY  487 

The  relative  frequency  of  these  tumors  may  be  roughly  estimated 
from  the  preceding  table  (p.  486)  made  up  of  reports  by  Watson  and 
Wilson/ 

Embryoma. — The  renal  tumors  of  childhood  were  usually  spoken 
of  as  sarcomata,  adenosarcomata  or  mixed  tumors  until  properly  classi- 
fied by  Wilms."     These  tumors,  like  most  other  malignant  growths,  re- 


FiG.  101. — Adenocarcinoma  of  the  Hypernephroma  Type. 

main  relatively  incapsulated  within  the  kidney,  so  that  one  usually 
finds  portions  of  renal  tissue  uninvolved  in  the  growth  even  after  this 
has  reached  twenty  pounds'  weight.  Like  other  embryomata  these 
growths  are  mixed  in  character,  and,  while  the  sarcomatous  elements  • 
predominate,  especially  in  the  large  tumors,  areas  resembling  carcinomas 
and  bits  of  enchondroma,  osteoma,  etc.,  can  be  found  in  the  growth 
unless  these  have  been  overrun  by  the  more  malignant  tissue.     These 

^  Ann.  of  Surg.,  April,  1913. 

*  "  Mischgeschwuelste  der  Niere, "  Leipzig,  1899. 


488  CYSTS  AND  TUMORS  OF  THE  KIDNEY 

\J 

growths  extend  by  lymphatic  continuity  into  the  perirenal  tissue  and 

by  venous  metastasis.     They  reach  an  enormous  size.  *^ 

"Hypernephroma." — The  propriety  of  this  title  has  been  gravely 
questioned  of  late  years.  But  inasmuch  as  they  are  widely  known 
under  this  name,  and  as  the  pathologists  have  not  yet  reached  any 
unanimity  in  their  interpretation  of  the  nature  of  these  tumors,  we 
may  still  continvie  to  call  them  "hypernephromata."  They  destroy 
life  before  reaching  anything  like  the  size  often  attained  by  the  tumors 
of  infancy ;  but  like  them  they  usually  occupy  only  a  portion  of  the 

kidney  even  after  they 
have  extended  into  the 
vessels  and  the  perirenal 
tissue.  The  early  pathol- 
ogists described  them  as 
malignant  lipomata  be- 
cause, in  their  growth  as 
well  as  in  their  mi- 
croscopic characteristics, 
they  show  a  certain  re- 
semblance to  fatty  tu- 
mor. Grawitz,  however, 
gave  them  the  name  of 
" hypernephroma  " 
after  showing  that  their 
structure  closely  resem- 
bles that  of  the  tumors  of 
the  adrenal  glands.  He 
inferred  that  they  were 
due  to  adrenal  inclusions,^  within  the  kidney,  such  as  have  occasionally 
been  found. ^  Of  late  years  this  theory  has  been  questioned  by  various 
writers,  notably  by  Wilson,  who  maintains  that  they  are  "mesotheliomata 
derived  from  the  nephrogenic  vesicles  which  had  failed  in  the  early 
embryo  to  form  a  tubular  connection  with  the  renal  pelvis."  Others  are 
satisfied  to  classify  them  simply  as  carcinomata. 

The  striking  microscopic  characteristic  of  these  growths  is  their 
great  variety  of  structure.  In  places^they  exhibit  a  structure  which 
suggests  the  cortex  of  the  adrenal  gland ;  they  are  very  vascular^  indeed, 
as  Watson  remarks,  their  stroma  may  be  said  to  be  formed  of  capillaries, 
so  that  in  places  they  suggest  angiosarcoma  and  endothelioma.  The 
cells  are  polygonal  or  columnar  in  shape,  and  their  large  lightly  staining 


Fig.  102. — Carcinoma  of  the  Kidney. 


^  Ann.  of  Surg.,  April,  1913. 

^Dunn  {Jour.  Path,  and  Bacteriol.,  1913,  xvii,  515)   classifies  them  as  (1)  true 
adrenal  rests,  (2)  adenopapillary  tissue  and  (3)   papilliferous  cysts. 


SOLID  TUMORS  OF  THE  KIDNEY  489 

bodies  have  given  rise  to  the  French  title  "carcinoma  with  clear  cells." 
With  the  breaking  down  of  certain  parts  of  the  tumor  one  may  see 
pictures  absolutely  characteristic  of  papillary  cystadenoma;^  while 
other  specimens  show  a  narrow  tubular  development  which  has  suggested 
the  title  "adenoma."  The  larger  cells  often  contain  fat  or  become 
vacuolated  when  this  disappears.  The  larger  tumors  usually  show  a 
necrotic  center. 

Carcinoma — Perhaps  the  above  tumors  are  but  one  form  of  renal 
carcinoma.  There  is,  however,  a  rare  clinical  type  of  carcinoma,  usually 
an  adenocarcinoma,  which  involves  the  whole  of  the  kidney  (Fig.  102). 

Sarcoma. — Spindle-celled,  round-celled,  and  mixed  sarcomata  are 
described.  The  latter  are  actually  embryomata,  but  the  spindle  and 
round-celled  varieties,  though  rare,  usually  occur  in  adult  life.  Wilson 
states  that  "most  of  the  few  true  sarcomata  of  the  kidney  develop 
primarily  in  adult  tissue  of  the  renal  capsule  and  involve  the  cortex 
secondarily." 

Other  Tumors. — The  papillary  cystadenomata  are  doubtless  all 
variants  of  the  "hypernephroma,"  so  are  the  adenomata,  benign  or 
malignant. 

Tumors  of  the  Renal  Pelvis See  page  493. 

Symptoms  of  Malignant  Growths 

The  symptoms  of  renal  tumor  are: 

Hematuria.  Urinary  symptoms. 

Tumor.  Compression  symptoms   (varicocele). 

Pain.  General  symptoms. 

Hematuria. — Hematuria  is  usually  the  first  symptom  of  renal  tumor 
in  the  adult.  This  was  the  first  symptom  in  138  out  of  257  cases  studied 
by  Albarran.^  Hematuria  occurred  during  the  course  of  the  disease 
in  235  out  of  357  cases. 

The  hematuria  is  cJiaracteristically  abundant,  painless,  spontaneous, 
and  not  influenced  by  motion  or  i;gst.  Penal  ^colic^^ay  result  from 
the  passage  of  clots  through  the  ureter.  These  clots  may  sometimes  be 
discerned  in  the  urine  by  their  wormlike  shape/  The  bleeding  may 
be  so  free  that  the  blood  only  clots  after  reaching  the  bladder.  I  have 
seen  four  cases  that  required  catheterization  to  free  the  bladder  of  clots. 

The  hematuria  may^ccuiunan^  years  before  any  other  symptom. 
Thus  HildebrandTias  reported  cases  in  which  the  intervals  between  the 
appearance  of  blood  and  any  other  symptom  of  tumor  were  eight  to 
twelve  years.     The  hematuria  may  be  so  profuse  as  to  cause  graven 
anemia. 

*Cf.  Kretschmer,  Surg.,  Gynec.  and  Obstet.,  1914,  xix,  766. 
■    ""Les  Tumeurs  du  Eein,"  Paris,  1903. 


^^  03 

o 


490 


SOLID  TUMORS  OF  THE  KIDNEY  491 

In  children  hematuria  is  much  rarer  than  in  adults.  Albarran 
found  it  only  22  times  in  140  cases. 

Renal  Tumor — Renal  tumor,  accompanied  by  little  or  no  pain,  is 
usually  the  only  symptom  of  renal  neoplasm  in  children  until  the  can- 
cerous cachexia  begins  to  show  itself. 

In  adults,  a  tumor  is  usually  discernible  at  the  time  of  operation. 
Albarran's  statistics  show  only  53  cases  out  of  257  in  which  tumor  was 
the  first  symptom. 

Pain. — Pain  was  one  of  the  first  symptoms  of  renal  tumor  in  the 
adult  in  91  of  Albarran's  257  cases,  and  occurred  during  the  course  of 
the  disease  134  times  in  303  cases.  Pain  is  usually,  but  not  always,  felt 
exclusively  in  the  loin. 

Urinary  Changes. — The  urinary  changes  consist  usually  in  a  dimi- 
nution of  renal  function,  the  presence  of  albuminuria,  and  sometimes  of 
microscopic  hematuria  or  of  blood  casts.     Pus  is  rare. 

Unfortunately  a  renal  tumor  7nay  exist  for  several  years  without 
impairing  the  renal  function.  Thus  in  one  of  my  cases  three  years 
after  the  initial  hematuria  radiography  showed  that  the  kidneys  were 
of  equal  size  and  the  urine  from  the  diseased  organ  showed  a  water 
and  urea  output  equal  and  the  phenolsulphonephthalein  output  superior 
to  that  of  its  fellow.     The  patient  died  two  years  later. 

Compression  Symptoms. — The  nerves,  the  ureter,  and  even  the  in- 
testine may  give  compression  symptoms  from  the  presence  of  a  large 
renal  growth.  The  important  symptom,  however,  in  this  connection  is 
varicocele.  Strikingly  large  varicocele  is  sometimes  one  of  the  symp- 
toms of  renal  tumor — evidence. of  compression  of  the  spermatic  vein. 
It  is  more  common  on  the  left  side  ttenTon'me  right,  and  Legueu  be- 
lieves that  the  presence  of  varicocele  is  evidence  that  the  renal  vein  is 
compressed  by  enlarged  lymph  glands.  According  to  this  thesis,  vari- 
cocele would  be  almost  a  contra-indication  to  operation ;  but  Albar- 
ran and  others  have  shown  that  there  may  be  marked  glandular  en- 
largement without  varicocele,  marked  varicocele  without  glandular 
enlargement.  I  have  encountered  varicocele  but  once.  The  cava  was 
invaded  by  the  growth.     The  patient  survived  nephrectomy  four  years. 

Fever  and  Cachexia. — Israel  ^  has  seen  intermittent  and  relapsing 
fever  in  18  cases  of  renal  and  adrenal  tumor.  It  may  be  an  early 
and  misleading  symptom.  The  cachexia  of  renal  tumors  differs  not 
at  all  from  that  due  to  malignant  growths  elsewhere. 

Clinical  Types 

Albarran  recognizes  the  four  following  clinical  types : 

1.  The  adult  type,  characterized  by  hematuria  and  tumor. 

^Deutsche  med.  Woehenschr.,  Jan.  12,  1911. 


492  CYSTS  AND  TUMORS  OF  THE  KIDNEY 

2.  The  hematuric  type  without  tumor. 

3.  The  tumor  type  without  hematuria  (the  common  type  among 
children). 

4.  The  painful  type. 

Diagnosis  of  Malignant  Renal  Growths 

The  diagnosis  presents  itself  under  two  phases : 

1.  When  tumor  is  absent. 

2.  When  tumor  is  present. 

Diagnosis  in  the  Absence  of  Tumor — If  no  tumor  can  he  felt 
in  either  kidney  region,  the  symptom  that  leads  to  the  suspicion  of  renal 
tumor  is  hematuria  {pain,  however,  was  the  initial  symptom  in  27  of 
Braasch's  ^  83  cases;  the  only  symptom  of  14) — ^hematuria,  painless, 
spontaneous,  profuse,  and  total  (i.  e.,  not  terminal  hematuria).  The 
fact  that  the  blood  clots  in  the  bladder  is  no  evidence  against  its  renal 
origin. 

Cystoscopy  and  ureter  catheterism  determine  whether  this  hema- 
turia occurs  in  the  bladder  or  descends  from  the  ureter  of  one  or  the 
other  kidney.  The  cystoscopy  should  be  performed  while  the  patient 
is  bleeding. 

The  question  then  arises,  is  the  hematuria  of  the  so-called  essential 
type,  or. is  it  due  to  neoplasm  ? 

Unfortunately  renal  tumors  so  small  as  not  to  be  palpable  are 
usually  surrounded  by  a  considerable  amount  of  normal  renal  tis- 
sue ;  hence  the  impairment  of  function  on  the  afflicted  side  may  be  in- 
significant. This  constitutes  one  of  the  greatest  dangers  in  the  diagnosis 
of  renal  hematuria. 

Under  such  circumstances  pyelography  should  be  employed.  This, 
too,  may  fail  to  show  recognizable  abnormality.  (It  failed  in  five  of 
Braasch's  22  cases.)  In  this  event  exploratory  nephrotomy  is  indicated 
if  the  patient  is  over  35  years  of  age. 

Diagnosis  ~m  the  Presence  ofT!umor — When  the  renal  neoplasm 
has  attained  sufficient  size  to  be  palpable,  the  fact  that  it  is  in  the  kidney 
and  not  in  one  of  the  surrounding  organs  may  usually  be  determined  by 
the  functional  renal  tests,  although  in  young  children  these  are  usually 
not  applicable,  and  one  must  depend  upon  the  physical  characteristics 
of  the  tumor  in  the  loin. 

The  presence  of  a  large  tumor  in  the  loin  of  the  child  almost 
invariably  means  malignant  growth  in  the  kidney. 

Renal  tumor  may  be  differentiated  from  cystic  disease  by  radiog- 
raphy and  pyelography;  from  other  retroperitoneal  growths  by  renal 
function  tests  and  pyelography. 

*Jour.  A.  M.  A.,  1913,  Ix,  274. 


SOLID  TUMORS  OF  THE  KIDNEY  493 

Treatment 

The  only  treatment  is  nepKrectomj^.  This  should  always  be  at- 
tempted unless  the  cachectic  condition  of  the  patient  or  functional 
deficiency  of  the  opposite  kidney  forbid. 

The  very  peculiar  features  of  nephrectomy  for  tumor  are  dwelt  upon 
elsewhere  (p.  698). 

Under  modern  conditions  the  mortality  of  nephrectomy  for  tumor  is 
little  more  than  that  for  tuberculosis.  The  Mayos  lost  but  seven  out 
of  61  nephrectomies.  But  recurrence  is  frightfully  common.  Among 
the  Mayos'  cases  27  died  in  from  one  to  five  years  and  27  were  last 
reported  alive.  But  of  these  only  12  had  been  followed  three  years, 
only  five  more  than  five  years.  Of  my  own  nine  cases  two  were  fixed. 
The  attempt  to  remove  them  was  fatal.  Of  the  others  only  three  were 
fairly  confined  to  the  kidney.  Two  of  these  survive,  apparently  well, 
one  and  three  years  after  nephrectomy.     The  others  died  of  recurrence. 

Tumors  op  the  Renal,  Pelvis  and  Ureter 

The  tumors  of  the  renal  pelvis  and  ureter  are  epithelial  in  character. 
Stuesser  ^  has  collected  the  reported  cases :  47  malignant  papillomata, 
and  11  epitheliomata.  The  tumors  originate  in  the  renal  pelvis,  and 
are  occasionally  propagated  down  the  ureter  and  into  the  bladder. 
Lower  ^  reports  a  case  of  malignant  papilloma  extending  from  the 
pelvis  of  the  kidney  to  the  bladder,  and  has  collected  18  similar  ones. 

The  papillary  tumors  are  of  the  same  character  as  those  of  the 
bladder,  the  epitheliomata  are  alleged  to  be  due  to  leukoplakia  or  similar 
inflammatory  changes  causing  the  epithelium  of  the  kidney  pelvis  to 
become  squamous  in  type.     They  may  be  secondary  to  stone. 

The  secondary  pathological  changes  are  due  to  obstruction  of  the 
ureter  by  the  growth  or  by  clots  which  result  in  hematonephrosis. 

The  symptoms  are:  bleeding,  renal  colic  and  the  development  of  a 
tumor  in  the  side. 

The  diagnosis  is  made  by  cystoscopy  which  reveals  blood  coming 
from  the  kidney  involved.  It  will  be  impossible  to  make  a  correct 
diagnosis  before  operation  unless  the  growths  have  been  propagated  to 
the  lower  end  of  the  ureter  and  bladder. 

The  treatment  is  ureteronephrectomy  with  removal  of  the  duct 
down  to  the  bladder  wall,  and  either  fulguration  or  excision  of  the 
adjoining  bladder  wall  for  the  treatment  of  the  vesical  tumors. 

Although  Israel  has  insisted  upon  the  importance  of  suspecting 
tumor  of  the  kidney  pelvis  in  all  cases  of  bladder  papillomata,  the  com- 

^Beitr.  s.  Uin.  CJiir.,  1912,  Ixxx,  595. 
'Surg.,  Gyn.  ^  Ohstet.,  Feb.,  1914,  151. 


494  CYSTS  AND  TUMORS  OF  THE  KIDNEY 

bination  of  the  two  conditions  is  extremely  rare.  I  have  endeavored  to 
excite  hemorrhage  from  growths  in  the  ureter  by  rather  roughly  pass- 
ing ureter  catheters  up  and  down  these  whenever  I  had  occasion  to 
fulgurate  a  bladder  papilloma  lying  near  the  ureter  orifice ;  but  I  have 
never  yet  succeeded  in  thus  obtaining  any  suggestion  of  tumor  of  the 
ureter. 


CHAPTER    LIT 
TUMORS  OF  THE  BLADDER  AND  URETHRA 

TUMORS  OF  THE  BLADDER 

The  great  majority  of  tumors  of  the  bladder  are  of  epithelial 
origin;  thus  I  have  personal  records  of  84  cases  of  papilloma  and 
carcinoma  with  no  other  varieties  represented,  excepting  a  single  lymph- 
adenoma.  Young  ^  records  117  cases  of  which  96  were  carcinomata, 
21  papillomata,  and  1  sarcoma.  Among  the  rarer  tumors  one  may 
mention  sarcoma,  myoma,  angioma,  and  epithelioma  and  adenoma. 
Epithelial,  dermoid  and  hydatid  cysts  have  also  been  observed. 

ETIOLOGY 

Little  is  known  of  the  etiology  of  tumors  of  the  bladder.  Irritation 
plays  the  important  part  in  only  two  tumors — the  epitheliomata,  which 
arise  from  areas  of  leukoplakia,  and  the  tumors  occurring  in  the  blad- 
der of  persons  working  in  anilin  dye  factories  ^  which  have  been  shown 
to  be  due  to  the  irritation  of  the  urine  caused  by  inhalation  of  the 
irritating  fumes. 

Carcinoma  of  the  bladder  is  extremely  rare  in  patients  under  forty 
years  of  age.  Papilloma  (as  judged  by  my  standard)  is  almost  always 
benign  under  fifty ;  yet  Iladda,^  who  states  that  in  a  series  of  5,000  car- 
cinomata less  than  1  per  cent  was  located  in  the  bladder,  and  none  oc- 
curred in  patients  under  twenty,  nevertheless  described  a  case  appar- 
ently due  to  the  irritation  of  stone  which  had  been  removed  when  the  lad 
was  nineteen  years  of  age.     The  carcinoma  appeared  5  years  later. 

Seventy-eight  per  cent  of  Albarran's  cases  were  in  men,  and  Judd  * 
records  84  cases  in  men  to  30  in  women. 

PATHOLOGY 

Papilloma. — This  neoplasm  has  been  gracefully  described  by  Thomp- 
son ^  as  follows : 

^Jour.  Am.  Med.  Assn.,  1913,  Ixi,  1857. 

'Jour.  Am.  Med.  Assn.,  1900,  xxxiv,  1256;  also  Beitr.  z.  Jclin.  Chir.,  1912,  Ixxx, 
206. 

^  Arch.  f.  Min.  Chir.,  1909,  Ixxxiii,  3. 

*Jour.  Am.  Med.  Assn.,  1912,  lix,  1788. 

■>"  Tumors  of  the  Bladder,"  London,  1884. 

495 


496  TUMORS  OF  THE  BLADDER  AND  URETHRA 

The  most  obvious  characteristic  of  the  growth  is  a  structure  in  which  the 
vesical  mucous  membrane  is  developed  into  fine  papillae,  which  consist  of 
long  fimbriated  processes  of  extreme  tenuity,  and  usually  form  a  group  arising 
from  a  small  circumscribed  base  (Fig.  106).  This  last-named  part  contains 
other  and  more  solid  structure  than  that  which  enters  into  the  papillae  them- 
selves. Sometimes  the  processes  are  almost  single,  threadlike  forms  arranged 
side  by  side,  and  undivided  for  a  considerable  distance ;  others  are  bifid,  generally 
more  compound  still;  some  may  be  described  as  digitate,  and  occasionally  the 
processes  radiate  and  suggest  forms  resembling  those  of  leaves.  Immersed 
in  fluid,  the  long  fimbriated  growths  float  out  like  slender-leaved  aquatic  plants 
in  deep  water,  and  when  removed  to  air  collapse  and  form  a  soft  mass  resem- 
bling a  small  strawberry. 

The  villi  are  composed  of  capillary  loops  covered  by  several  layers 
of  columnar  epithelium  (Fig.  104).  The  "more  solid  structure"  of 
the  pedicle  is  fibrous  and  vascular.  Independent  villi  may  spring 
from  the  wall  of  the  bladder  itself,  or  the  pedicle  may  be  short  and 
broad,  giving  the  growth  a  sessile  appearance  (PL  I). 

The  pathological  diagnosis  of  papilloma  is  beset  with  the  greatest 
difficulty.  That  a  bladder  tumor  conforms  grossly  and  even  micro- 
scopically to  the  papilloma  type  is  no  proof  that  its  complete  removal 
will  not  be  followed  by  relapse  either  in  the  form  of  papilloma  or  of 
carcinoma.  Indeed  I  have  known  a  competent  pathologist  to  pro- 
nounce the  original  tumor  carcinoma,  the  recurrence  papilloma,  nor 
did  confrontation  alter  his  either  opinion.  So  frequent  is  recurrence 
of  papilloma  (estimated  by  Eafin  ^  at  57  per  cent)  that  we  may  still 
echo  Guyon's  aphorism,  "We  await  in  the  clinic  the  papilloma  of 
statistics" — for  in  the  clinic  papilloma  of  the  bladder  is  often  a  malig- 
nant  growth,  even  when  the  microscope  reveals  no  malignancy  about  it. 
Nevertheless  certain  pathologists  persistently  cling  to  the  hope  of 
microscopic  diagnosis  of  papilloma  that  may  show  some  agreement 
with  the  clinical  facts.  Thus  in  the  symposium  of  the  American 
Urological  Association  in  1915  Buerger  stood  out  absolutely  for  the 
sufficiency  of  microscopic  diagnosis  while  Geraghty  granted  it  fallible. 
This  skepticism  seems  justifiable.  We  may  recognize  a  type  of  obvi- 
ously benign  papilloma,  single,  pedunculated,  readily  destroyed  by 
cauterization ;  a  malignant  papilloma,  occurring  almost  exclusively  after 
the  fiftieth  year,  often  multiple,  sometimes  ulcerated,  slow  to  heal  by 
burning ;  and  a  papillary  carcinoma  with  infiltrated  base.  Microscopic 
examination  of  these  growths  gives  a  fairly  consistent  picture.  In 
papillomata  the  characteristics  of  malignancy  are  summed  up  by 
Buerger,  as  follows : 

Cells  manifesting  irregularities  in  size  and  shape ;  nuclei  rich  in  chromatin, 
deeply  staining  and  of  bizarre  shape;  cells  with  atypical  mitoses;  giant  cells 

^French  Urol.  Assn.,  vol.  ix. 


TUMORS  OF  THE  BLADDER 


497 


and  multi-nucleated  cells.    All  these,  when  occurring  in  papilloma  of  the  bladder, 
indicate  the  presence  or  beginning  of  carcinomatous  change. 

On  the  other  hand,  certain  of  the  atypical  appearances  noted  in  papil- 
lomata  are  not  to  be  regarded  as  indicative  of  malignancy.  Some  of  these 
are  degenerative,   others  metaplastic.     There  maj'^  be,   first,   the  foi-mation   of 


m 

Mm 


Fig.  104. — Papilloma  of  Bladdek. 

glands  or  cysts,  the  conversion  of  the  epithelium  into  cylindrical  and  cuboidal 
epithelium  with  the  acquisition  of  the  property  of  secretion ;  second,  intense 
inflammatory  invasion  with  round  cells,  infiltration  of  the  epithelium  with  fine 
fusiform  cells,  probably  angioblasts;  third,  conversion  of  some  of  the  cells  into 
squamous  cells,  such  as  are  within  the  normal  type  of  cell. 

Carcinoma — ISTot  only  do  we  see  tumors  illustrating  every  step  from 
the  simple  papilloma  to  the  papillary  carcinoma,  but  many  obsei'vers 
are  not  unwilling  to  admit  the  actual  metaplasia  of  tumors  from  one 
to  the  other,  -  The  prolonged  histories  of  certain  cases  that  ultimately 
prove  to  be  microscopically,  pathologically  and  clinically  carcinoma ; 
^he  occurrence  in  different  parts  of  the  bladder  of  typical  carcinoma, 


498 


TUMORS  OF  THE  BLADDER  AND  URETHRA 


and  typical  papilloma  and  the  recurrence  after  operation  of  papilloma 
as  carcinoma  or  carcinoma  as  papilloma ; — by  all  these  tests  either  the 

microscope  is  not  to  be  de- 
pended upon  at  all,  or  true 
papilloma  does  change  into 
true  carcinoma  in  the  blad- 
der. 

In  its  gross  characteris- 
tics, carcinoma  of  the  blad- 
der presents  three  types : 
the  papillary  carcinoma 
(Fig.  106)  with  infiltra- 
tion of  its  base  and  sur- 
rounding mucosa ;  the  lob- 
ulated  carcinoma  (Fig. 
107)  which,  while  it  may 
appear  superficially  a  pa- 
pilloma, does  not  yield  to 
fulgTiration,  is  likely  to 
be  ulcerated,  to  have  a 
broad  base,  and  to  show 
some  infiltration  about 
this  base;  and  the  carcinomatous  ulcer.  The  diagnosis  of  such  tumors, 
however,  must  be  made  primarily  by  the  removal  of  a  specimen  which 
shows  typical  fully  developed  carcinoma.     The  carcinomatous  ulcer  is 


Fig.  105. — Carcinoma  of  the  Bladder. 


Fig.  106. 


-Papillary  Carcinoma.    (A1- 
barran  ) 


Fig.  107. — Lobulated  Carcinoma.   (A1- 
barran.) 


not  an  ulceration  or  incrustation  of  a  lobulated  or  villous  growth,  for 
this  may  occur  with  either  of  the  two  types  already  mentioned.  It 
has  rather  the  gross  characteristics  of  the  epithelioma  of  the  lip.  It 
is  a  hard  indolent  ulcer  without  any  tendency  to  papillary  outgrowth; 


'  TUMORS  OF  THE  BLADDER  499 

With  the  first  two  types  of  tumor  there  is  a  distinct  tendency  to  surface 
implantation  and  multiplicity,  the  secondary  tumors  being  sometimes 
apparently  wholly  papillomatous;  but  the  carcinomatous  ulcer  is  char- 
acteristically single  and  its  microscopical  characteristics  verge  toward 
the  epithelioid  type. 

Other  Types  of  Epithelial  Neoplasm — A  number  of  authentic  cases 
of  colloid  or  mucous  carcinoma  of  the  bladder  have  been  reported.^ 
Since  there  are  normally  no  glands  in  the  bladder,  these  tumors  must 
arise  either  from  glandular  inclusion  or,  as  seems  more  probable,  from 
degeneration  of  a  patch  of  cystitis  granulosa. 

Cases  of  adenocarcinoma  are  reported  from  time  to  time,  and  ma}'' 
have  a  like  origin,  but  most  of  them  are  secondary  to  carcinoma  of  the 
intestines. 

True  epithelioma  seemingly  always  arises  from  leukoplakia,  and 
shows  itself  either  by  a  propagation  of  this  condition  or  by  an  ulcera- 
tion thereof. 

Cystitis  cystica  might  almost  be  classed  among  the  neoplastic  con- 
ditions of  the  bladder  for  it  is  not  infrequently  found  with  carcinoma 
(Fig.  70). 

Propag^ation. — Papilloma  is  apparently  propagated  only  by  contact 
inoculation.  Carcinoma  is  propagated  in  three  ways:  (a)  by  contact 
inoculation,  (h)  by  infiltration  of  the  surrounding  tissues,  and  (c)  by 
lymphatic  involvement. 

Contact  inoculation  occurs  in  two  ways.  Either  the  growth  appears 
at  various  points  in  the  mucosa  that  fall  against  each  other  when  the 
viscus  is  empty,  or  postoperative  relapse  occurs  in  the  suprapubic  scar 
(due  to  inoculation  at  the  time  of  operation). 

Lymphatic  involvement  carries  the  carcinoma  to  the  iliac  glands  and 
thence  to  the  lumbar  glands. 

Pasteau  ^  has  shown  that  the  glands  along  the  iliac  vessels  are  en- 
larged in  43  per  cent  of  all  sessile  tumors  of  the  bladder  and  in  85  per 
cent  of  infiltrated  tumors. 

Secondary  Lesions — Any  tumor  of  the  bladder  may  also  becoriie 
inflamed,  ulcerated,  or  incrusted  with  salts  of  lime.  Perforation  of  the 
bladder  is  most  exceptional. 

The  secondary  changes  in  the  urinary  organs  are  of  greater  im- 
portance. The  tumor  acts  in  very  much  the  same  way  as  a  hyper- 
trophied  prostate.  It  offers  a  point  of  least  resistance  for  the  origin  of 
infection,  and,  sooner  or  later,  it  obstructs  the  orifice  of  the  urethra  or 
of  the  ureter,  thus  setting  up  the  secondary  retention  with  infection, 
pyelonephritis,  etc. 

^  Chute  and  Crosbie,  Boston  Med.  ^  Surg.  Jour.,  1912,  clxvii,  583. 
* ' '  Etat  du  systeme  lyinphatique  dans  les  maladies  de  la  vessie  ct  de  la  pros- 
tate," Paris,  1898,  pp.  46,  52. 


500       TUMORS  OF  THE  BLADDER  AND  URETHRA 

Other  Tumors — The  other  tumors  of  the  bladder  are  not  sufficiently 
frequent  to  require  more  than  a  summary  consideration. 

Sarcoma.^- — Round-celled,  spindle-celled,  mixed-celled,  l^nnphosar- 
coma,  fibrosarcoma;  myosarcoma,  myxosarcoma,  alveolar,  giant-celled, 
telangiectatic,  and  chondrosarcoma  are  described.  The  tumor  usually 
encroaches  but  little  on  the  cavity  of  the  bladder.  It  appears  either  as 
a  hard  sessile  growth  or  an  intramural  infiltration.  Its  surface  may  be 
smooth,  papillary,  or  ulcerated. 

Myxoma  -  (Polyp). — Myxoma  occurs  only  in  children.  The  growth 
is  usually  a  fibromyxoma  or  a  myxosarcoma.  The  surface  of  the  tumor 
is  lobular  and  smooth,  resembling  polypus  of  other  regions. 

Myofibroma.^ — The  tumor  being  benign,  usually  small,  and  of 
firm  texture,  passes  unnoticed  during  life,  unless  it  interferes  with 
micturition,  becomes  infected  or  ulcerated. 

AxGioMA. — This  has  been  well  described  by  Albarran.*  It  has  no 
clinical  significance. 

Cysts. — Several  varieties  of  cysts  occur  in  cystitis.  They  have  no 
clinical  significance.  Urachus  cysts  receive  special  consideration  at  the 
end  of  this  chapter. 

Dermoid  cysts  occasionally  occur  in  the  wall  of  the  bladder.  They 
are  diagnosed  only  when,  after  rupture,  hair  from  them  is  passed  in  the 
urine.     This  s;)Tiiptom,  pilimiction,  is  pathognomonic. 

Echinococcus  cysts  °  grow  in  the  pelvis  and  burst  into  the  bladder. 

SYMPTOMS 

Epithelial  Tumors 

Hemorrhage. — The  first,  the  last,  and  often  the  only  symptom  of  a 
tumor  of  the  bladder  is  hemorrhage.  In  general,  the  more  villous  the 
tumor  the  more  profuse  the  bleeding.  Hence,  with  such  tumors  as 
myofibroma,  hemorrhage  is  rare. 

The  characteristic  hemorrhage  of  a  neoplasm,  whether  renal  or  ves- 
ical, begins  without  cause  or  warning,  continues  copious  and  painless, 
unaffected  by  rest,  diet,  or  medication,  and  ceases,  as  it  begins,  without 
apparent  rhyme  or  reason.  Its  cessation  may  leave  the  urine  entirely 
normal  and  the  patient  lulled  into  a  false  sense  of  security  by  what  he 
considers  his  happy  escape  from  a  perilous  condition.  A  profuse  hem- 
orrhage of  this  character  is  almost  pathognomonic  of  neoplasm.  Yet 
bleeding  from  a  tumor  may  not  be  characteristic.     It  may  be  mild  and 

*Munwes,  Zeitschr.  f.  Urol.,  1910,  iv,  No.  11. 
'^  O'Neill,  Trans.  Am.  TJrolog.  Assn.,  1915,  ix,  1. 
3  Blum,  Folia  Urol.,  1910.  v,  314. 
*"Tumeurs  de  la  vessie, "  1S91. 
*  Salvador,  SewAma  med.,  1912,  xix.  449. 


TUMORS  OF  THE  BLADDER  501 

continuous,  associated  with  cystitis,  evoked  by  instrumentation,  or 
apparently  amenable  to  treatment.  It  may  not  be  the  initial  symptom. 
In  short,  it  may  assume  any  form.  But  to  be  characteristic  it  must 
be  spontaneous,  profuse,  unalterable,  and  unaccompanied  by  any  other 
symptom. 

Usually  the  hemorrhage  grows  more  severe  and  recurs  more  fre- 
quently as  the  disease  progresses.  But  this  is  by  no  means  always  the 
case.  There  may  be  intervals  of  years  between  the  hemorrhages ;  indeed, 
Albarran  cites  a  few  cases  in  which  the  hemorrhage  stopped  entirely 
after  spontaneous  detachment  of  the  growth. 

Hemorrhage  from  neoplasm  of  the  bladder  may  be  excited  by  the 
introduction  of  any  instrument  (especially  a  metal  one)  into  that  organ, 
and  when  thus  produced  it  assumes  its  characteristics  of  profusion, 
painlessness  (except  for  the  passage  of  clots),  resistance  to  treatment, 
and  spontaneous  cessation. 

Pain  and  Dysuria — These  symptoms  usually  appear  long  after  the 
first  hemorrhage.  Exceptionally,  pain  and  dysuria  precede  the  bleed- 
ing. I  have  seen  three  papillomata  that  did  not  bleed,  but  gave  rise 
solely  to  the  symptoms  of  cystitis.  Pain  may  be  evoked  by  the  passage 
of  clots ;  it  may  be  due  to  cystitis,  to  obstruction  of  the  urethra,  or  to 
the  infiltration  of  the  bladder  muscle  by  the  tumor  itself. 

Retention — The  passage  of  urine  may  be  suddenly  arrested  by  a 
large  clot  or  by  the  tumor.  All  the  familiar  forms  of  acute  and  chronic 
retention,  with  or  without  infection,  are  encountered.  Tumors  in  the 
region  of  the  ureteral  orifice  sometimes  obstruct  that  duct  partially  or 
completely. 

Cystitis — The  course  of  the  disease  is  commonly  divided  into  two 
stages:  (1)  before  infection,  (2)  after  infection.  Yet  cystitis  may  be 
the  first  symptom  of  tumor.  The  tumor  is  a  point  of  least  resistance. 
Instruments  introduced  into  the  bladder  often  bring  infection  with 
them,  and  thus  in  one  way  or  another,  at  one  time  or  another,  cystitis 
occurs.  When  once  the  tumor  has  become  inflamed  there  is  little  hope 
of  overcoming  the  inflammation  except  by  removing  the  tumor ;  and  if 
this  is  not  done  early  the  inflammation  spreads  to  the  kidney,  and  is 
largely  instrumental  in  the  patient's  final  taking  off. 

The  cystitis  of  tumor  of  the  bladder  is  usually  ammoniacal  and 
leads  to  incrustation.  The  dysuria  is  severe,  and  small  quantities  of 
foul  urine  full  of  pus  and  blood  are  passed  with  infinite  pain  and 
straining. 

Course  of  the  Disease 

Among  140  cases  collected  by  Albarran  the  first  symptom  was 
hematuria  in  109  (75  per  cent),  dysuria  in  10  (7  per  cent),  cystitis  in 
5,  frequency  in  5,   and  in  the  remainder,   various   combinations  of 


502       TUMORS  OF  THE  BLADDER  AND  URETHRA 

hemorrliage  (in  10),  dysuria  (in  7),  cystitis  (in  2),  retention  (in  2), 
the  passage  of  shreds,  and  once  the  extrusion  of  the  tumor  from  the 
female  urethra. 

Before  infection  occurs,  the  symptoms  are  mild.  Indeed  they  are 
all  too  mild.  For  if  we  may  judge  from  their  size  some  tumors — even 
carcinomata — exist  for  years  without  causing  symptoms.  Were  it  not 
for  the  hemorrhages  that  occur  from  time  to  time,  the  patient  would 
give  little  thought  to  his  urinary  organs.  These  hemorrhages,  though 
profuse,  rarely  cause  any  grave  anemia.  This  condition  continues  for 
months  or  years.  The  patient's  general  health  is  excellent,  and  he  may 
bear  his  bleeding  in  silence  and  come  to  the  surgeon  only  after  cystitis 
has  set  in. 

When  cystitis  occurs  the  symptoms  promptly  become  more  aggra- 
vated, and  the  patient,  exhausted  by  the  loss  of  blood  and  distressed  by 
the  constant  spasm  of  his  bladder,  grows  rapidly  weaker. 

The  Urine — The  appearance  of  the  urine  depends  upon  whether 
cystitis  or  hemorrhage  is  present  at  the  time  of  examination.  Between 
whiles  it  may  be  entirely  normal,  or  there  may  be  microscopical  and 
chemical  evidence  of  hemorrhage — viz.,  the  presence  of  red  blood  cells 
and  albumin. 

When  cystitis  exists  there  is  commonly  some  hemorrhage  as  well, 
so  that  the  urine  contains  both  pus  and  blood. 

The  urine  may  also  be  searched  for  shreds  of  tumor  tissue.  These 
are  especially  common  with  papillomatous  growths.  They  sometimes 
are  as  large  as  a  pea,  resemble  blood  clots  in  appearance,  and  are  easily 
overlooked.  If  found,  they  confirm  the  diag-nosis  of  tumor,  but  do  not 
denote  the  character  of  the  gTowth,  since  simple  papillae  may  sprout 
from  a  carcinoma. 

Other  Tumors 

Fibromyomata,  which  may  occur  at  any  age,  usually  give  no  symp- 
toms whatever;  they  may  ulcerate  and  cause  hemorrhage,  they  may 
mechanically  interfere  with  the  emptying  of  the  bladder  and  cause 
retention,  and  thus  cause  cystitis.  Inasmuch  as  these  neoplasms  are 
not  malignant  their  course  is  essentially  slow. 

The  other  malignant  tumors  of  the  bladder,  sarcoma  and  myxoma 
(though  the  former  may  occur  in  adult  life),  are  essentially  the  tumors 
of  childhood,  and  relatively  frequent  in  the  first  years  of  life,  up  to 
the  fifth  year.  The  clinical  picture  is,  therefore,  singularly  obscure, 
the  symptoms  of  cystitis  with  hematuria  and  retention  of  urine  are 
often  mistaken  for  stone.  The  growth  is  sometimes  discovered  by  cys- 
toscopy, but  usually  only  by  external  examination  when  it  has  reached  a 
very  large  size.     O'lSTeil  ^   comments  upon  the  bad  prognosis  of  the 

^  Trans.  Am.   Urol.  Assoc,  19]5,  ix,  1. 


TUMORS  OF  THE  BLADDER  503 

tumors  of  childhood.    He  mentions  three  recoveries  of  at  least  one  year 
after  removal  of  polypi. 

DIAGNOSIS 

The  majority  of  bladder  tumors  are  discovered  by  cystoscopy  after 
their  presence  has  been  suggested  by  a  typical  hemorrhage.  Of  the 
remainder  some  are  discovered  by  cystoscopy  undertaken  for  frequent 
and  painful  urination  and  pyuria,  v^^ithout  any  idea  that  the  tumor  is 
the  cause  of  this ;  others  are  discovered  accidentally  before  they  have 
begun  to  cause  symptoms  and  the  remainder  are  disclosed  by  other  meth- 
ods of  examination  after  they  have  reached  a  size  which  precludes  the 
possibility  of  successful  treatment. 

The  cystoscope  is,  therefore,  the  only  method  of  diagnosing  tumors 
of  the  bladder  at  a  time  when  they  are  worth  diagnosing,  and  capable 
of  being  treated. 

Unwillingness  to  submit  every  case  of  hematuria  to  instant  cystos- 
copy is  the  cause  of  our  bad  record  in  the  treatment  of  bladder  tumors. 

'No  characteristics  of  the  blood  itself,  no  presence  of  large  clots  or 
small  clots,  determines  the  diagnosis. 

A  carcinoma  that  has  grown  to  a  considerable  size  and  infiltrated 
the  bladder  wall  may  perhaps  be  felt  either  by  the  stone  searcher  inside 
the  bladder,  or  as  an  induration  in  the  base  of  the  bladder  by  rectal 
touch,  or  even  if  it  is  sufficiently  large  by  bimanual  palpation;  but 
such  large  tumors  present  not  the  remotest  hope  of  cure. 

Cystoscopic  Diagnosis — The  cystoscope  may  leave  one  in  doubt 
as  to  the  presence  of  tumor  in  the  bladder  under  two  conditions:  in 
the  first  place,  when  the  tumor  is  too  small ;  in  the  second,  when  it  is 
too  large. 

The  small  pedunculated  tumor,  especially  if  situated  in  an  unusual 
part  of  the  bladder,  may  entirely  escape  the  cystoscopist.  I  have  once 
overlooked  a  bladder  tumor  of  this  character ;  indeed  I  have  seen  an 
infiltrating  carcinoma  of  the  bladder  vault  the  size  of  a  trade,  dollar 
that  had  eluded  two  cystoscopic  examinations.  The  mistake  can  usually 
be  avoided  by  careful  observation  of  the  region  where  the  bladder 
tumors  usually  grow.     These  are : 

1.  The  regions  about  the  ureter  orifices,  especially  just  beyond  and 
outside  of  them; 

2.  The  vault,  where  carcinoma  is  not  uncommon; 

3.  The  bladder  neck  and  that  part  of  the  vault  just  above  this  as 
well  as  the  adjacent  portions  of  the  deep  urethra.  Papillomata  are 
rare  in  other  parts  of  the  bladder.  If  they  extend  to  the  fundus  and 
vault,  they  usually  do  so  to  one  side  or  the  other  of  the  median  line; 
thus  suprapubic  section  for  papilloma  of  the  bladder,  while  it  may 
encounter  tumors  in  the  median  line  at  the  point  where  the  bladder  is 


504       TUMORS  OF  THE  BLADDER  AND  URETHRA 

divided,  shows  that  the  central  portion  of  the  fundus  is  relatively  clear, 
and  that  the  papillomata  tend  to  implant  in  two  parallel  bands,  running 
anteroposteriorly  from  the  region  of  the  ureter  mouth. 

Small  carcinomata  have  usually  the  same  distribution,  though  the 
epitheliomatous  ulcer  is  more  likelv  to  occur  in  the  midline,  either  of 
the  fundus  or  of  the  vault. 

The  large  tumor  is  difficult  to  diagnose  by  the  cystoscope,  not  on 
account  of  its  size,  but  because  of  the  severe  cystitis  with  which  it  is 
often  accompanied.  Cystoscopy  may  be  practically  impossible,  or  if 
performed,  may  reveal  a  bladder  that  will  hold  but  a  few  teaspoonsful 
of  urine,  and  the  walls  of  which  are  intensely  inflamed,  and  covered 
with  phosphates,  or  slough.  Under  these  circumstances,  one  may  w^ell 
remain  in  doubt  as  to  whether  one  is  dealing  with  a  carcinomatous 
growth,  an  incrusted  simple  ulcer,  or  a  stone  covered  with  slime  and 
blood.  A  decision  may  be  reached  by  tapping  the  "stone"  with  the 
end  of  the  cystoscope,  or  by  excising  a  specimen  with  the  cystoscopic 
forceps. 

The  cystoscopic  forceps  is  used  as  a  routine  measure  by  some  opera- 
tors for  the  diagnosis  of  the  exact  nature  of  all  tumors  of  the  bladder. 
I  have  protested  against  its  routine  use  on  the  gTound  of  possible  dis- 
semination of  tumors.  There  seems  to  be  no  unanimity  among  path- 
ologists, however,  as  to  whether  this  is  a  real  danger  or  not.  It  is 
certainly  no  danger  when  there  is  already  ulceration  of  a  growth.  But 
if  the  pathologist,  with  the  w^hole  tumor  in  his  hand,  cannot  say  whether 
it  will  be  for  all  time  a  carcinoma  or  a  papilloma,  he  certainly  cannot 
do  so  from  the  small  specimens  that  can  be  removed  by  forceps. 

The  cystoscopist  should  endeavor  to  make  his  diagnosis  on  the 
clinical  features  of  the  tumor  as  revealed  to  the  cystoscope.  This  he 
can  usually  do  with  almost  absolute  certainty.  If  there  is  any  doubt 
in  his  mind,  then  let  him  by  all  means  take  specimens  from  the  growth 
in  order  to  clear  up  that  doubt  as  rapidly  as  possible;  for  it  is  these 
clinically  doubtful  but  pathologically  malig-nant  growths  that  are  the 
only  carcinomata  of  the  bladder  we  can  expect  to  cure. 

In  the  majority  of  instances,  therefore,  the  cystoscopist  shall  depend 
upon  his  eye  for  a  diagnosis.  The  ultimate  criterion  of  that  diagnosis 
shall  be  whether  the  tumor  can  be  destroyed  by  fulgiiration  or  not. 
For  while  recognizing  the  malignancy,  or  potential  malignancy,  of 
every  epithelial  tumor  of  the  bladder,  we  draw  the  line  here  as  else- 
where in  the  body  on  the  basis  of  treatment.  The  tumor  that  can  be 
readily  cured  by  treatment  is  not  malignant.  The  success  or  failure 
of  the  fulguration  treatment  of  papillary  tumors  of  the  Madder  deter- 
mines their  malignayicy. 

Contra-indications  to  Cystoscopic  Fulguration. — Some  years  ago  I 
endeavored  to  lay  down  rules  for  this  clinical  distinction,  and  further 


TUMORS  OF  THE  BLADDER  505 

experience  has  Dot  materially  clianged  mv  opinion.     The  four  contra- 
indications to  cystoscopic  desiccation  are: 

1.  Hardness  of  the  tumor. 

2.  Intractable  cystitis. 

3.  Sloughing  or  ulcerated  tumor. 

4.  Multiplicity  and  size  of  tumors. 

Some  of  these  contra-indications  are  not  absolute,  and  all  may  be 
elucidated  by  a  few  words  of  description. 

Haedxess  of  Tl'moe. — The  hardness  of  a  vesical  tumor  may  be 
appreciated  in  several  ways.  Eectal  or  vaginal  touch  may  reveal  an 
induration  in  the  region  of  the  trigone ;  bimanual  palpation  may  disclose 
the  presence  of  a  large  infiltrating  tumor;  or  cystoscopy  may  reveal 
an  ulcerated  indurated  carcinoma.  All  such  conditions,  we  repeat, 
contra-indicate  cystoscopic  treatment. 

IxTEACTABLE  Cystitis. — In  the  four  years  since  Beer  introduced 
the  desiccation  treatment,  I  have  never  seen  a  case  with  intractable 
cystitis  that  was  suitable  for  intravesical  treatment.  The  patients 
suffering  from  relatively  benign  papilloma  may,  it  is  true,  suffer  from 
time  to  time  the  most  intense  cystitis.  But  this  can  be  relieved  by  the 
ordinary  bladder  irrigations  to  the  point  of  ameliorating  the  patient's 
suffering,  and  permitting  fulgnration. 

But  the  real  intractable  cystitis  is  not  appreciably  relieved  by  any 
local  application;  is  only  intensified  by  the  introduction  of  the  cysto- 
scope ;  permits  only  the  most  inadequate  and  unsatisfactory  observation, 
and  of  itself  almost  prohibits  treatment.  Such  a  case  when  operated 
upon  will  be  found  to  have  either  a  sloughing  carcinoma,  or  some  con- 
dition other  than  tumor. 

Sloughing  oe  Ulceeated  Tumoe. — A  tumor  that  shows  upon  its 
surface  any  •extensive  sloughing  is  truly  malignant.  However,  the  mere 
presence  of  small  sloughs  does  not  forbid  all  hope  of  success  by  cysto- 
scopic treatment.  Here,  then,  the  contra-indication  is  not  absolute.  Let 
the  cystoscopist,  however,  proceed  with  caution,  and  if  a  few  treatments 
do  not  manifestly  control  the  growth,  let  him  waste  no  further  time, 
but  quickly  have  recourse  to  the  open  operation. 

Multiplicity  and  Size  of  Tumoes. — The  contra-indication  here  is 
even  less  definite  than  that  of  sloughing.  Multiplicity  of  tumors  is  a 
perfectly  obvious  suggestion  of  malignancy.  Such  malignancy  may  be 
of  two  types.  The  multiple  papillomata  either  spring  from  an  under- 
lying carcinoma  (e.  g.,  an  infiltration  from  the  cei^nx  uteri)  or  are 
propagated  by  surface  contact.  In  the  latter  case  the  malignancy  is  a 
superficial  one.  Indeed,  a  very  large  proportion  of  bladder  papillomata 
are  multiple '  when  first  seen.  Yet  a  majority  of  these  are  certainly 
amenable  to  treatment  by  fulgiiration. 

Size  and  multiplicity  of  tumors,  therefore,  present  a  problem  in 


506  TTIMORS  OF  THE  BLADDER  AXD  URETHRA 

practical  surgery  rather  than  a  question  of  malignancy.  Every  urologist 
must  decide,  in  the  light  of  his  own  experience,  whether  it  is  more 
profitable  to  cut  or  to  burn  a  given  patient.  It  so  happens  that  only 
one  of  my  cases  has  defied  treatment  on  account  of  the  size  or  multi- 
plicity of  gTowth.  Yet  no  doubt  some  of  these  might  have  been  more 
quickly  cured  by  the  knife.  It  is  noteworthy  thai  though  I  have 
verified  a  cure  by  cystoscopy  ten  times,  a  year  or  more  after  the  last 
treatment,  none  of  the  ten  had  more  than  two  tumors  when  treatment 
was  beg-un.  Three  others  with  multiple  tumors  (5,  5,  and  7)  were 
clean  when  last  seen ;  but  doubtless  they  will  relapse  again. 

In  a  certain  sense  the  patient's  age  bears  on  the  question  of  malig- 
nancy. Thus  among  my  cases  there  were  eighteen  with  single  tumors, 
of  whom  all  but  four  showed  symptoms  before  the  age  of  fifty.  On 
the  other  hand,  of  the  nine  with  multiple  tumors,  all  began  after  the 
fiftieth  year. 

Failure  of  Cystoscopic  Fulguration. — But  in  order  to  do  justice  to 
his  patients  the  urologist  must  be  quick  to  recog-nize,  not  only  the 
contra-indications  to  an  attempt  at  fulgnration,  but  also  the  evidence  of 
failure  in  this  treatment.  He  is  dealing  with  a  growth  which  is  at 
least  potentially  malignant.  Perhaps  the  very  days  during  which  he  is 
making  up  his  mind  as  to  the  advisability  of  fulgiiration  are  those  dur- 
ing which  the  tumor  is  actually  spreading  to  the  pelvic  lymph  nodes, 
thus  making  a  curable  case  incurable.  The  fear  of  carcinoma  must  be 
ever  in  his  soul,  and  a  tumor,  however  small  and  apparently  superficial, 
that  resists  fulgiiration  must  be  promptly  excised. 

PSEITDOCAECIXOMA 

It  is  doubtless  unnecessary  at  this  date  to  insist  upon  the  chronic 
infiltration  of  the  mucosa  about  the  base  of  the  tumor  following  fulgnra- 
tion.  It  simulates  an  infiltrating  carcinoma.  It  may  persist  for  at 
least  three  months,  as  in  Cabot's  case,  and  our  only  safeguard  against 
it  is  the  knowledge  that  it  was  not  there  when  we  began  treatment,  and 
that  it  may  persist  for  several  months  after  the  last  burn. 

The  only  serious  complication  of  such  an  ulcer  is  staphylococcus 
infection  causing  phosphatic  incrustations.  Such  a  complication  I 
have  seen  but  once. 

PROGNOSIS 

Thus  the  prognosis  of  papilloma  grows  worse  the  older  the  patient 
afilicted,  while  the  prognosis  of  carcinoma  grows  worse  the  younger  the 
patient  afflicted ;  for  here,  as  elsewhere,  carcinoma  in  the  young  usually 
grows  with  gTeat  rapidity.     Beyond  this  the  prognosis  is  quite  indefi- 


TUMORS  OF  THE  BLADDER 


507 


nite.  One  of  my  patients  bled  for  twenty-five  years  before  I  burned 
oft"  his  single  tumor  quite  readily  in  three  or  four  treatments;  he  has 
remained  well  for  three  years  since  that  time.  Others  come  after  their 
first  bleeding  with  a  bladder  full  of  tumors,  or  with  a  carcinoma  so  far 
advanced  as  to  be  irremediable. 

The  prognosis  after  treatment  is,  perhaps,  the  most  important  point. 


V 


3. 


yr  • 


Fig.  108. — Carcinomatous  Infiltration  beneath  Apparently  Normal  Mucosa. 


After  suprapubic  section  even  for  simple  papilloma  relapse,  as  has 
been  stated,  has  been  extremely  common — at  least  50  per  cent  of  the 
tumors  returning.  After  fulgTiration  relapses  are  far  less  common  if 
we  may  judge  from  an  experience  of  the  last  five  years.  With  fulgiira- 
tion  we  may  probably  expect  from  five  to  ten  per  cent  of  relapses  within 
the  first  two  years.  We  have  not  followed  the  treatment  long  enough  to 
know  how  rapidly  this  tendency  to  relapse  diminishes. 


508  TUMORS  OF  THE  BLADDER  AND  URETHRA 

TREATMENT       ' 

The  treatment  depends  upon  the  diagnosis.  If  the  patient's  tumor 
is  clearly  a  papilloma  it  should  be  treated  by  f ulgTiration ;  if  doubtful, 
it  should  still  be  treated  by  fulgiiration,  but  the  progress  of  the  cure 
checked  by  excision  of  portions  of  the  tumor  for  pathological  diagnosis, 
and  by  impartial  study  of  the  effect  of  the  fulgTiration.  If  it  is  not 
satisfactory,  suprapubic  section  should  be  resorted  to  at  once. 

If  the  tumor  resists  fulguration,^  or  if  frankly  carcinomatous  (or  if 
there  are  so  many  papillomata  that  it  seems  unwise  to  waste  time  over 
fulgurating  them  when  a  single  operation  would  clear  up  the  whole 
lot)  fulgTiration  is  out  of  the  question,  and  we  have  only  to  determine 
whether  it  is  worth  the  patient's  while  to  undergo  a  suprapubic  section 
or  not.     Two  classes  of  tumor  certainly  merit  operation : 

1.  Multiple  papillomata  or  papillary  malignant  growths  that  have 
not  infiltrated  the  bladder  wall.  These  should  be  exposed  by  supra- 
pubic section,  for  destruction  by  cautery  of  the  whole  growth  and  its 
base. 

2.  Infiltrating  growths  are  always  operable  if  they  are  in  the  vault 
of  the  bladder,  or  in  the  fundus.  ISTeoplasms  involving  the  trigone  and 
the  ureter  mouth  may  be  removed  with  greater  difficulty,  the  ureter 
being  transplanted  to  some  other  portion  of  the  bladder  wall,  but  these 
tumors  produce  lymphatic  metastasis  so  early  that  the  hope  of  radical 
cure  is  small. 

Such  cases,  perhaps,  and  the  more  advanced  disseminated  bladder 
carcinomata  certainly,  are  candidates  for  radium  treatment  or  total 
cystectomy.  I  have  seen  but  one  apparent  cure  of  a  desperate  case  by 
radium.  The  mortality  of  total  cystectomy  was  prohibitive  until  Wat- 
son suggested  dividing  the  operation  into  two  parts,  and  making  the 
preliminary  ureterostomy  or  nephrostomy  a  separate  operation ;  the 
mortality  has  thus  been  reduced  to  about  50  per  cent.  But  although 
total  cystectomy  eifectively  and  completely  removes  the  primary  tumor 
of  the  bladder,  and  dissection  of  the  pelvic  lymphatics,  comparable  to 
that  performed  by  Wertheim  for  carcinoma  of  the  uterus,  may  be  done, 
the  operation  does  not  greatly  commend  itself.  Its  unpublished  mortal- 
ity is  certainly  far  higher  than  that  of  statistics.  The  patient  with  ure- 
teral or  kidney  fistulae  is  by  no  means  in  a  comfortable  or  presentable 
state,  no  matter  what  apparatus  he  may  wear,  and,  if  the  cystectomy 
has  been  performed  for  a  tumor  that  really  requires  it,  the  prospect 
of  metastatic  recurrence  is  indeed  forbiddingly  great.  I  have  three 
times  performed  cystectomy  for  the  relief  of  symptoms,  and  the  symp- 
toms have  been  relieved— by  a  higher  power  than  mine. 

^  Geraghty  cured  a  previously  obstinate  case  by  renewed  f ulguration  after  ap- 
parently ineffectual  exposure  to  radium. 


NEOPLASMS  OF  THE  URETHRA  509 


NEOPLASMS  OF  THE  URETHRA 

Although  any  urethral  neoplasm  may  occur  in  a  virgin  urethra,  the 
neoplasms  that  occur  in  the  male  are  found  almost  exclusively  in  pa- 
tients who  have  had  gonorrhea,  and  the  papillomata  are  almost  exclu- 
sively a  feature  of  chronic  gonorrheal  urethritis. 

The  following  varieties  will  be  described : 
Papilloma. 
Angioma. 
Fibroma. 
Cysts. 
Carcinoma. 
Sarcoma. 

Angioma  and  sarcoma  are  usually  met  with  in  the  female  urethra. 
The  other  varieties  of  tumor  are  found  almost  exclusively  in  the  male. 

Papilloma — Papilloma  of  the  urethra  has  quite  the  same  charac- 
teristics as  the  so-called  venereal  wart  that  occurs  upon  the  external 
genitals.  In  the  anterior  urethra  they  are  fairly  common  about  the 
meatus ;  but  they  have  been  observed  deeper  down  the  urethra,  as  far  as 
the  bulb.  Modern  posterior  urethroscopy  reveals  minute  papillomata 
in  almost  every  chronically  inflamed  deep  urethra  (p.  203).  They  are 
usually  multiple.  They  appear  through  the  urethroscope  as  pointed, 
warty  growths  which  bleed  very  readily.  They  usually  disappear  after 
a  course  of  dilatation,  or  yield  to  the  high  frequency  spark.  Large 
masses  of  warts  in  the  anterior  urethra  may  be  cured  by  inserting  the 
urethroscopic  tube  up  to  the  mass  of  tumors,  so  that  they  project  almost 
into  its  lumen.  A  thick  swab  of  cotton  upon  a  probe  is  then  introduced 
and  violently  rubbed  to  and  fro,  scraping  off  the  papillary  growths. 
The  immediate  hemorrhage  is  profuse,  but  is  readily  checked  by 
pressure.     The  remaining  fragments  may  be  removed  by  fulguration. 

Angioma. — Angioma  of  the  female  urethra,  commonly  spoken  of  as 
vascular  polyp  or  urethral  caruncle,  appears  close  to  the  external  meatus, 
usually  on  the  floor  of  the  urethra.  The  growth  is  common  at  middle 
life,  though  Geraldes  (Mark^)  has  reported  a  case  in  a  child  three 
years  of  age.  This  tumor  is  exquisitely  sensitive  and  causes  agonizing 
pain  on  urination,  which,  combined  with  insistent  infrequency  of  uri- 
nation, may  almost  drive  the  patient  insane.  It  may  be  cured  by  ex- 
cision or  by  destruction  with  the  cautery. 

A  few  instances  of  similar  growths  have  been  reported  in  the  navic- 
ular fossa  of  the  male  urethra. 

Fibroma.— Fibromata  are  very  rare  and  are  usually  mixed  growths 
— fibromyxomata  or  fibromyomata.     They  occur  singly,  usually  in  the 

^  Trans.  Am.  Urolog.  Assoc,  1908,  vol.  ii. 


510       TUMORS  OF  THE  BLADDER  AND  URETHRA 

bulb,  but  may  involve  the  prostatic  urethra.  They  are  extremely  rare 
in  the  female.  Through  the  urethroscope  they  appear  as  smooth,  minute 
tumors  with  a  distinct  pedicle. 

Cysts — Minute  cysts  of  the  urethral  glands  are  sometimes  seen  in 
cases  of  chronic  urethritis.  Cyst  of  the  prostatic  utricle  is  a  rare 
autopsy  finding  in  infants.  Cysts  of  the  inflamed  posterior  urethra 
have  no  known  clinical  significance. 

Carcinoma.^ — Though  the  male  urethra  may  be  invaded  by  carci- 
noma of  the  glans  penis  or  of  the  prostate,  primary  urethral  carcinoma 
is  extremely  rare.  I  have  seen  but  three  cases.  Some  50  cases  have 
been  reported  by  Preiswerk  and  Mall  (cf.  Barney^).  The  tumor  be- 
gins at  or  near  the  bulbous  urethra.  The  symptoms  are  those  of  deep 
urethral  stricture,  resilient  and  indurated.  The  presence  of  carcinoma 
is  not  suspected  until  perineal  section  reveals  the  indurated  character 
of  the  stricture. 

The  urethroscope  distinguishes  two  types  of  tumor.  One  type  is 
reddish  and  warty;  the  other  white,  presenting  the  aspects  of  a  warty 
leukoplakia  of  the  tongue.  The  striking  characteristic  of  the  growth  is 
its  hardness  when  the  attempt  is  made  to  curette  it.  This  characteristic 
establishes  the  diagnosis.  In  the  few  reported  cases  the  only  treatment 
attempted  has  been  excision. 

Mark  states  that  of  21  microscopically  confirmed  cases  all  recurred 
within  one  year,  excepting  one  of  Oberlaender's,  which  had  no  recur- 
rence twenty-one  months  after  a  resection,  and  Carcey's,  which  showed 
no  recurrence  ten  months  after  a  total  emasculation. 

Dr.  Abbe  is  at  present  treating  a  case  for  me  by  applications  of 
radium,  and  the  tumor  seems  to  be  gradually  disappearing. 

Primary  carcinoma  of  the  female  urethra  may  begin  as  a  caruncle. 
It  usually  involves  the  vulva.  Excision  should  include  the  vaginal 
glands.    Whitehouse  ^  has  collected  44  cases. 

Sarcoma — Sarcoma  ^  occurs  usually  in  the  female  urethra.  Eight 
cases  of  fibrosarcoma  and  one  of  melanosarcoma  have  been  reported. 
They  grow  rapidly,  and  none  of  them  has  been  cured. 

^Bost.  Med.  and  Surg.  Jour.,  1907,  clvii,  790.  Cf.  also  Zeitschr.  f.  Urol,  1913, 
vii,  30. 

^Proc.  Boyal  Soc.  Med.,  Jan.,  1912. 

» Cf .  Mark,  Ann.  Surgery,  1912,  Iv,  416. 


CHAPTER   LIII 

INJURIES   TO   THE  KIDNEY  AND   URETER— ANEURYSM   OF   THE 

RENAL  ARTERY 

SUBPARIETAL  INJURIES— RUPTURE 

SuBPAEiETAL  injury  of  the  kidney  is  rare.  Among  13,455  autopsies 
there  occurred  31  instances  of  ruptured  kidney  (Morris  and  Herzog^). 
Among  198  cases  collected  by  Tuffier,  136  occurred  in  adult  men,  and 
in  only  2  were  both  kidneys  injured.  Two  hundred  and  eighty-one  of 
Kiister's  306  cases  were  males.  Of  272  in  which  the  particulars  are 
stated,  142  occurred  on  the  right  and  118  on  the  left  side,  12  being 
bilateral  (Morris).  In  a  series  of  89  cases  of  contusion  of  the  abdom- 
inal viscera  the  kidneys  were  injured  35  times  (Makins  ^). 

The  kidneys  may  be  contused  by  a  variety  of  accidents,  such  as 
kicks,  buffer  accidents,  falls,  and  even  simple  muscular  effort.  The 
lower  ribs  may  be  broken  and  driven  into  the  organ,  and  many  of  the 
accidents  are  explicable  only  on  the  theory  that  the  kidney  is  burst 
either  by  the  impact  of  the  ribs  compressing  it  against  the  spine 
(Morris)  or  by  increased  intrarenal  tension  (Kiister). 

PATHOLOGY 

Subcapsular  Hemorrhage — Morris  relates  two  instances  of  ex- 
travasation of  blood  under  the  fibrous  capsule  of  the  kidney,  caused  by 
slight  muscular  exertion  and  producing  severe  pain.  Calculus  was  sus- 
pected, but  nephrotomy  revealed  only  a  subcapsular  hematoma,  the 
evacuation  of  which  effected  a  cure.  He  believes  that  this  form  of 
rupture  is  not  uncommon,  and  that  the  compression  of  the  parenchyma, 
perhaps  increased  by  repeated  small  hemorrhages,  explains  the  irregu- 
lar and  protracted  course  of  the  symptoms  in  some  cases,  until  ulti- 
mately the  capsule  gives  way,  the  blood  and  disorganized  parenchyma 
escape  into  the  perirenal  space,  and  this  late  hematoma  demands  opera- 
tion which  reveals  a  disorganized  kidney. 

Laceration   of  the   Parenchyma — The  kidney   substance  may  be 

lacerated  in  any  direction  and  to  any  extent  (Fig.  109).     Portions  of 

^Morris,  op.  cit. 

'  Quoted  by  Watson  and  Cunningham, 

511 


512 


INJURIES  TO  THE  KIDNEY  AND  URETER 


the  organ  may  be  lopped  off,  or  the  whole  kidney  may  be  reduced  to  a 
pulp  or  torn  away  from  its  vessels  and  ureter.  If  the  capsule  and 
ureter  remain  intact  the  primary  reaction  is  often  slight;  but  usually 
both  are  torn,  and  as  a  result  blood  and  urine  are  immediately  poured 
into  the  perirenal  space,  at  first  distending  it  and  forming  a  tumor 
in  the  loin,  and  later  escaping  from  the  orifice  at  the  lower  part  of  the 
perirenal  fascia   (or  through  any  tear  in  it)   to  form  a  more  or  less 

generalized  subperitoneal  infiltration. 
This  extravasation  of  blood  and  urine  is 
more  or  less  rapid  in  proportion  to  the 
extent  of  the  rupture. 

The  blood  also  pours  down  the  ureter 
into  the  bladder  and  is  expelled  there- 
from (hematuria). 

Associated  Lesions. — Laceration 
of  the  perirenal  fat  may  occur  alone  or 
in  connection  with  rupture  of  the  kid- 
ney. It  is  unimportant.  Fortunately 
laceration  of  the  peritoneum  is  rare.  In 
the  adult  there  is  a  distinct  layer  of  fat 
between  the  kidney  and  the  peritoneum, 
which  permits  complete  disintegration 
of  the  former  without  any  injury  to  the 
latter ;  but  in  children  this  layer  of  fat 
is  not  developed,  and,  therefore,  rupture 
of  the  peritoneum  permitting  rapidly  fatal  hemorrhage  is  relatively 
frequent  in  them  but  rare  in  the  adult.  It  occurred  in  12  per  cent  of 
Watson's  cases.  Rupture  of  the  renal  artery  and  vein  is  also  rare. 
Rupture  of  the  liver  or  spleen  results  in  free  hemorrhage  which  makes 
the  renal  lesion  a  secondary  consideration.  Fracture  of  the  lower  ribs 
and  puncture  of  the  diaphragm,  the  pleura,  and  the  lung  are  among 
the  associated  lesions. 

The  Process  of  Repaik. — Slight  injuries  of  the  renal  parenchyma 
may  heal  promptly  with  but  little  associated  inflammation,^  and  peri- 
renal hematoma  of  some  size  may  disappear  within  a  few  weeks  by 
diffusion  and  absorption.  Yet  the  usual  outcome  of  rupture  of  the 
kidney — if  the  patient  survives  the  immediate  results  of  the  injury — 
is  infection  of  the  urohematoma,  suppuration  throughout  the  wound, 
and  gangrene  of  such  portions  of  the  organ  as  have  been  partially  or 
completely  torn  away.  The  urinous,  purulent  collection  burrows  in 
various  directions  until  the  patient  succumbs  or  the  surgeon  intervenes. 
Other  results  are  infarction,  secondary  hemorrhage,  aneurysm  of 
the  renal  artery,  and  traumatic  hydronephrosis. 
*  Yarrow,  N.  Y.  Med.  Jour.,  1900,  Ixxi,  1. 


Fig.  109. — Ruptured  Kidney. 


SUBPARIETAL  INJURIES— RUPTURE  513 

Traumatic  Hydro^vepiirosis. — Traumatic  hydronephrosis  and 
pseudohydronephrosis  are  very  rare  results  in  trauma.  True  hydro- 
nephrosis has  been  reported  only  17  times.  ^  Pseudohydronephrosis  is 
a  urinous  sac  whose  walls  are  made  up  partly  of  the  renal  pelvis,  partly 
of  cicatrized  perirenal  tissue. 

SYMPTOMS 

The  symptoms  of  renal  injury  may  be  overshadowed  by  those  due 
to  rupture  of  other  viscera. 

Apart  from  the  systemic  shock  and  the  local  pain  and  ecchymosis 
due  to  the  bruising  of  the  abdominal  wall,  there  are  four  cardinal  symp- 
toms of  rupture  of  the  kidney  directly  referable  to  the  organ  itself. 
These  are  hematuria,  variations  in  the  quantity  of  urine  excreted, 
tumor,  and  pain. 

Hematuria — The  passage  o"^  bloody  urine  after  a  contusion  of  the 
loin  is  the  most  characteristic  symptom  of  ruptured  kidney.  Yet  the 
hematuria  may  occur  when  the  kidney  is  not  ruptured,"  and,  on  the 
contrary,  there  may  be  no  hematuria,  even  though  the  kidney  is  rup- 
tured. Thus  the  blood  cannot  reach  the  bladder  if  there  is  (1)  sub- 
capsular rupture,  (2)  occlusion  of  the  ureter  by  clot,  or  (3)  avulsion 
of  the  kidney  from  the  ureter.  Yet  hematuria  was  a  feature  in  80 
per  cent  of  the  cases  collected  by  Watson.^ 

The  course  of  the  bleeding  is  very  irregular.  The  blood  usually 
flows  freely  for  several  days,  and  then  ceases,  either  because  the  hem- 
orrhage has  stopped,  or  because  the  ureter  becomes  obstructed  by  clots. 
Blood  cells  and  albumin  may  persist  in  the  urine  for  many  days,  and 
recurrence  of  bleeding  is  not  uncommon.  Exceptionally  there  is  no 
hematuria  for  the  first  few  days.  The  blood  passed  is  usually  sufficient 
in  quantity  to  dye  the  urine  a  deep  red ;  yet,  as  a  rule,  the  actual  amount 
of  blood  thus  lost  is  not  alarming. 

Variations  in  the  Quantity  of  Urine. — During  the  first  day  after  the 
injury  there  is  oliguria,  perhaps  anuria,  from  shock.  Continued  anuria 
indicates  rupture  of  both  kidneys,  or  else  incapacity  of  the  opposite 
kidney  (if  there  be  one)  to  act,  and  is  therefore  an  indication  for 
immediate  nephrotomy.  But  usually  a  polyuria  replaces  the  primary 
oliguria,  and  lasts  two  or  three  days  or  longer.  There  may  be  reflex 
dysuria  or  retention. 

*Wiklbo]z,  Zeitschr.  f.  Urol,  1910,  iv,  No.  4. 

*  Morris  gives  a  long  list  of  exceptional  causes  of  hematuria  after  contusion  of 
the  loin,  such  as  slight  contusion  of  the  kidney,  renal  congestion,  thrombosis  of  the 
renal  vessels,  stone,  malaria,  villous  tumor  of  the  bladder.  But  the  only  feature  of 
clinical  importance  is  the  persistence  of  bleeding.  Uncontrollable  bleeding,  from 
whatever  cause,  demands  operation. 

'Boston  Med.  and  Surg.  Jour.,  July  9,  16,  1903. 


514  INJURIES  TO  THE  KIDNEY  AND  URETER 

Tumor — The  extravasation  of  blood  and  urine  about  the  kidney 
develops  a  tumor  in  the  loin.  This  swelling  may  appear  immediately, 
or  its  advent  may  be  delayed  several  days,  or  no  tumor  may  ever  appear. 
The  tumor  is  usually  quite  diffuse,  filling  the  whole  loin  and  perhaps 
extending  even  to  the  groin.  The  swelling  is  elastic,  but  fluctuation 
cannot  be  made  out.  General  abdominal  tension  from  the  accumulation 
of  flatus  and  from  the  tenderness  of  the  bruised  parietes  may  obscure  a 
large  perirenal  hematoma. 

Pain. — The  pain  of  a  ruptured  kidney  is  an  inconstant  symptom. 
The  superficial  contusion  produces  local  pain  and  tenderness;  the  pas- 
sage of  clots  through  the  ureter  may  evoke  renal  colic,  apd  the  distention 
of  the  kidney,  or  its  compression  by  effused  blood,  may  produce  an  active 
pain  radiating  chiefly  to  the  groin  and  testicle,  and  perhaps  causing 
retraction  of  the  latter. 


COURSE  OF  THE  DISEASE 

1.  The  Injury  Is  Slight. — There  is  some  shock,  a  temporary  oligu- 
ria, and  hematuria.  After  a  few  days  the  urine  becomes  quantita- 
tively and  qualitatively  normal.  ISTo  notable  tumor  appears  in  the  loin, 
and  the  patient  is  well  within  ten  days  or  so. 

2.  The  injury  is  apparently  slight,  but  the  symptoms,  instead  of 
growing  less,  or  perhaps  after  an  apparent  remission,  become  more 
severe.  The  lumbar  tumor  grows  larger,  pulse  and  temperature  run 
high,  the  digestive  functions  are  not  properly  established,  the  abdomen 
remains  distended  and  tympanitic,  there  is  constipation,  anorexia,  per- 
haps vomiting,  the  tongTie  is  dry,  the  patient  listless  and  irritable.  This 
clinical  picture  indicates  progressive  urinary  toxemia  and  sepsis,  and 
calls  for  prompt  drainage  if  the  patient  is  to  be  saved.  The  presence 
of  pleurisy,  pneumothorax,  or  edema  of  the  lung  must  not  be  over- 
looked. 

3.  The  Injury  Is  Severe.— At  first  the  patient  is  dazed,  unconscious, 
or  in  a  state  of  collapse.  Hematuria  and  hematoma  develop  rapidly. 
He  may  fail  rapidly  and  die  of  shock,  of  internal  hemorrhage,  of  sup- 
pression, or,  later,  of  septic  complications.  Or  the  hematoma  may  be 
gradually  absorbed  or  become  infected. 

4.  The  Injuries  Are  Numerous. — In  the  most  serious  cases  the  renal 
rupture  is  only  one  among  several  visceral  injuries.  Rapidly  fatal 
intraperitoneal  hemorrhage  may  occur  from  the  kidney,  liver,  or  spleen. 
The  triple  infliction  of  shock,  hemorrhage,  and  peritonitis  can  be  com- 
bated only  by  immediate  abdominal  section  with  slight  hope  of  success. 

5.  Septic  Cases. — No  case,  however  mild,  is  free  from  the  danger  of 
sepsis  until  the  temperature  has  remained  normal  several  days.  Most" 
large  perirenal  hematomas  suppurate  unless  operated  upon. 


SUBPARIETAL  INJURIES— RUPTURE  515 

6.  Traumatic  Hydronephrosis.— Exceptionally  the  hematoma  be- 
comes encysted,  forming  the  so-called  traumatic  or  pseudohydrone- 
phrosis. 

DIAGNOSIS 

While  slight  injuries  to  the  kidneys  may  be  overlooked,  especially 
if  overshadowed  by  more  important  lesions  of  the  other  viscera,  a  kid- 
ney rupture  of  any  great  significance  always  manifests  itself  by  loin 
tumor,  usually  associated  with  hematuria  and  oliguria  or  anuria. 

The  cystoscope  and  ureteral  catheter  complete  the  diagnosis. 

TREATMENT 

The  treatment  of  shock  is  of  the  first  importance.  Opium  must  be 
sparingly  employed  for  fear  of  masking  the  symptoms.  The  catheter 
should  be  employed  with  the  most  minute  antiseptic  precautions,  for  the 
bloody  vesical  pool  is  more  than  usually  receptive  of  infection,  and  in- 
fection is — after  the  primary  shock  and  hemorrhage  have  passed — the 
only  noteworthy  danger  to  the  patient. 

But  all  these  measures  are  palliative  at  best.  By  them  the  symp- 
toms are  modified,  but  the  essential  features  of  the  case — the  hemor- 
rhage, the  function  of  the  opposite  kidney,  the  infection  of  the  peri- 
renal hematoma — are,  to  all  intents,  unafi^ected.  Only  by  the  knife 
can  the  surgeon  reach  these,  and  thus  the  momentous  questions  in  the 
treatment  of  rupture  of  the  kidney  are,  whether  to  operate  and  when 
to  operate. 

Immediate  operation  is  required  only  when  the  patient  fails  to  rally 
well  from  his  shock.  The  possibility  of  intraperitoneal  hemorrhage  or 
rupture'  of  some  of  the  other  viscera  will  lead  the  surgeon  to  fortify  the 
patient  by  a  large  intravenous  infusion,  and  then  to  operate,  in  the 
desperate  hope  of  averting  the  fatal  issue.  Indeed  my  experience  coin- 
cides with  that  of  Michelson  ^  who  states  that  apart  from  laceration  of 
the  renal  artery  and  vein,  which  may  prove  immediately  fatal,  the  pa- 
tients do  not  bleed  to  death.  He  reports  30  cases  treated  expectantly 
without  a  death  from  hemorrhage. 

After  the  first  shock  is  over  expectant  treatment  may  be  continued 
on  condition  that  the  patient  grows  progressively  stronger.  Yet  the 
surgeon  must  be  ready  to  operate,  and  the  patient  and  his  friends  pre- 
pared to  submit,  as  soon  as  any  unfavorable  symptom  manifests  itself. 
The  usual  indication  for  operation  at  this  juncture  is  continued  hemor- 
rhage, as  evinced  by  the  growing  tumor  in  the  loin,  for  "it  is  not  the 
visible  loss  of  blood  by  the  bladder,  but  the  easily  overlooked  but  far 
more  dangerous  bleeding  into  the  perinephritic  tissues,   or  into  the 

^  Arch.  f.  Min.  Chir.,  1911,  Ixxxxvi,  No.  3. 


516  INJURIES  TO  THE  KIDNEY  AND  URETER 

peritoneal  cavity^  that  should  receive  the  chief  attention"  (Keen^). 
Anuria  persisting  for  twenty-four  hours  is  an  indication  for  imme- 
diate operation.  Finally,  beginning  sepsis,  suggested  by  an  unfavorable 
temperature  and  pulse,  must  be  cut  short  by  operative  drainage. 

Although  severe  wounds  in  the  kidney  have  been  known  to  heal,  the 
prospects  of  cases  treated  expectantly  are  not  good.  Thus,  among  273 
uncomplicated  cases  treated  expectantly  (Watson),  81  (30  per  cent) 
died,  and  among  174  operated  cases,  32  (18  per  cent)  died,  while  of  the 
complicated  cases  treated  expectantly,  31  out  of  56  (60  per  cent)  died, 
and  of  the  59  complicated  cases  operated  upon,  26  (41  per  cent)  died. 
I  have  operated  upon  4  uncomplicated  cases,  with  1  death  by  ileus. 

The  Operation. — The  surgeon  employs  the  incision  with  which  he  is 
most  familiar,  as  speed  is  all-important.  The  choice  between  the  ab- 
dominal and  the  lumbar  route  depends  upon  whether  any  other  visceral 
lesions  are  suspected.  Though  the  abdominal  route  affords  quicker  con- 
trol of  the  renal  artery,  the  lumbar  incision  is  habitually  employed. 
Upon  incision  of  the  fascial  envelope,  clots,  blood,  bloody  urine,  or  pus 
exudes,  and  should  be  quickly  washed  awaj.  If  copious  bleeding  is  en- 
countered, the  renal  artery  must  be  clamped  or  tied  immediately, 
though,  as  a  general  rule,  the  hemorrhage  may  be  controlled  by  suture 
of  the  kidney  and  packing.  The  earlier  operators  performed  nephrec- 
tomy for  rupture  of  the  kidney,  as  they  did  for  every  other  surgical 
affection  of  the  kidney,  but  this  gi*aye  operation  is  rarely  necessary. 
Generous  drainage  will  allow  for  the  expulsion  of  such  detached  frag- 
ments of  kidney  tissue  as  the  surgeon  overlooks.  Secondary  nephrec- 
tomy may  be  required  if  prolonged  suppuration  ensues. 

WOUNDS  OF  THE  KIDNEY 

Wounds  of  the  kidney  (other  than  ruptures)  are  extremely  rare. 
Even  in  military  practice  they  are  unusual.  Of  incised  and  punctured 
wounds  (excluding  bullet  wounds)  there  are  no  instances  recorded  in 
the  "Medical  History  of  the  War  of  the  Eebellion."  Kiister  -  collected 
43  cases.  In  10  there  were  severe  injuries  to  other  organs,  and  of  these 
6  died  (60  per  cent),  while  among  the  31  uncomplicated  cases  there 
were  only  4  deaths  (12.9  per  cent).  Keen  records  8  cases  with  2  deaths. 
Among  Kiister's  cases  10  were  operated  upon  (2  primary  and  6  sec- 
ondary nephrectomies),  with  no  deaths;  Keen  records  4  nephrectomies 
without  a  death. 

Morris  sums  up  the  diagnostic  features  of  the  condition  as  follows : 
"It  may  be  stated  (1)  that  a  wound  in  the  renal  region  succeeded  by 

^Annals  of  Surgery,  1896,  xxiv,  138. 
'Deutsch.  Klinik,  1896,  lii,  1,  221. 


ANEURYSM  OF  THE  RENAL  ARTERY  517 

the  escape  of  -urine  througli  the  wound  is  conclusive  of  injury  to  the 
kidney;  (2)  that  such  a  wound  quickly  succeeded  by  the  discharge  yer 
urethram  of  urine  heavily  mixed  with  blood,  or  of  pure  blood,  is  aknost 
conclusive,  if  not  quite  so;  (3)  that  such  a  wound  succeeded  by  reten- 
tion of  urine,  or  lumbar  or  abdominal  pain  and  dysuria,  even  without 
hematuria,  is  highly  suggestive  of  a  superficial  wound  of  the  kidney,  or 
of  a  deeper  wound  and  the  blockage  of  the  ureter;  (4)  that  hematuria 
succeeded  by  traumatic  peritonitis  is  strong  evidence  of  an  injured 
kidney." 

The  chief  clinical  features  of  a  penetrating  wound  of  the  kidney, 
other  than  the  symptoms  of  rupture  of  that  organ  are :  ( 1 )  External 
hemorrhage,  (2)  greater  likelihood  of  infection  from  particles  of  cloth- 
ing and  dirt  carried  into  the  wound,  (3)  frequent  involvement  of  the 
peritoneum  and  of  the  other  abdominal  viscera,  (4)  prolapse  of  the  kid- 
ney, if  the  wound  is  extensive. 

Treatment. — The  treatment  is  much  the  same  as  that  of  rupture, 
except  that  exploration  of  the  wound  for  the  purpose  of  cleansing  it,  and 
exploratory  abdominal  section  to  insure  the  safety  of  the  other  viscera 
are  more  often  necessary. 

GUNSHOT  WOUNDS 

Although  the  recorded  cases  of  gunshot  wounds  of  the  kidney  show 
a  very  high  mortality — viz.,  59  deaths  among  85  cases  in  the  War 
of  the  Rebellion,  and  8  deaths  among  15  cases  in  the  Franco-Prussian 
War — it  is  evident  that  this  death  rate  is  due  to  associated  injuries. 
(Thus  Edler  ^  collected  20  uncomplicated  cases  with  5  deaths,  and  18 
complicated  cases  with  15  deaths.) 

The  only  special  features  of  these  wounds  are  (1)  the  explosive 
effect  of  high-velocity  projectiles — similar  to  that  observed  in  the  other 
semisolid  viscera — (2)  the  advantage  of  employing  the  x-ray  to  locate 
the  bullet. 

ANEURYSM  OF  THE  RENAL  ARTERY 

Morris  has  collected  19  instances  of  aneurysm  of  the  renal  artery, 
of  which  12  were  traumatic  in  origin,^  He  calls  attention  to  this  very 
rare  condition  because,  apparently,  it  is  always  fatal  (if  of  any  size) 
unless  the  patient  submits  to  operation.  The  aneurysm  ruptures,  caus- 
ing a  spontaneous  perirenal  hematoma. 

The  symptoms  are  tumor,  pain,  and  hematuria.  It  is  remarkable 
that  pulsation  is  rarely  detected.  Morris  detected  a  loud  systolic  bruit 
in  his  case,  but  no  thrill.     The  diagnosis  is  made  by  operation. 

^Arch.  f.  Idin.  Chvr.,  1887,  xxxiv,  379. 

'Lippens   (Jour,  de  Chir.,  1913,  xi,  1)   has  collected  23  cases.     . 


518  INJURIES  TO  THE  KIDNEY  AND  URETER 

The  treatment  is  operative.  The  aneurysmal  sac  should  be  disturbed 
as  little  as  possible  until  the  pedicle  is  secured.  Albert,  Hahn,  and 
Keen  have  operated  successfully;  Morris  unsuccessfully.  A  transperi- 
toneal operation  presents  a  better  field  for  securing  the  renal  vessels  than 
does  the  lumbar  route. 


RUPTURE  AND  WOUNDS  OF  THE  URETER 

Rupture. — Subcutaneous  rupture  of  the  ureter  is  very  rare.  Mor- 
ris ^  finds  24  reported  cases,  of  vi^hich  he  rejects  12  and  classifies  the 
others  as  verified  (3),  probable  (4),  and  possible  (5).  Macdonald,  of 
Minneapolis,  has  added  an  authentic  case.^  The  small  size,  loose  at- 
tachments, and  projected  position  of  the  ureter  render  it  peculiarly 
likely  to  escape  injury  except  from  a  penetrating  wound. 

It  is  quite  impossible  to  distinguish  rupture  of  the  ureter  from  rup- 
ture of  the  renal  pelvis  except  by  operation. 

Wounds. — Accidental  wounds  of  the  ureter  are  even  more  uncom- 
mon. Morris  has  found  only  5  reported  cases  (2  bullet  wounds),  and 
quotes  Otis's  conjecture  that  these  injuries  do  not  come  to  the  surgeon's 
notice  because  the  trunk  vessels  are  likely  to  be  punctured. 

Operative  Wounds. — 

The  ureter  is  injured  probably  in  from  1  to  3  per  cent  of  all  intraperitoneal 
operations  upon  the  female  pelvic  organs.  This  accident  is  more  common  by 
the  vaginal  than  by  the  abdominal  route. 

The  causes  of  these  injuries  are:  (1)  displacement  or  intimate  involve- 
ment of  the  ureter  by  pathological  structures  in  the  pelvis,  especially  uterine 
and  ovarian  tumors;  (2)  congenital  abnormalities;  and  (3)  lack  of  care  by  the 
operator. 

The  different  kinds  of  ureteral  injuries,  stated  approximately  in  the  order 
of  the  frequency  of  their  occurrence,  are:  (1)  ligation,  (2)  clamping,  (3) 
kinking  (these  three  usually  produce  complete  occlusion),  (4)  incision,  (5)  re- 
section, and  (6)  destruction  of  blood  supply.  Complete  obstruction  may  lead 
to  the  following  results,  named  approximately  in  the  order  of  their  seriousness : 
Local — (a)  infection — 15  per  cent,  (b)  fistula — 24  per  cent,  (c)  hydronephrosis— 
80  per  cent,  {d)  general  renal  atrophy — less  than  20  per  cent  in  Barney's 
series.  General — (e)  toxemia — very  rare,  (/)  anuria — 1.6  per  cent,  {g)  no 
symptoms — 21  per  cent.  The  mortality  of  unilateral  ureteral  obstruction  is 
18  per  cent.     (W.  Jones.)* 

Symptoms. — 1.  If  the  ureter  is  tied  oif  or  otherwise  occluded  the 
kidney,  after  going  through  a  preliminary  period  of  congestion  and 
slight  dilatation,  atrophies  without  dilatation.     In  such  a  case,  if  the 

^"Surg.  Dis.  of  the  Kidneys  and  "Ureter,"  London,  1900,  ii,  332. 

""Med.  Becord,  1901. 

*Am.  Jour.  Obstet.,  1914,  Ixx,  329. 


RUPTURE  AND  WOUNDS  OF  THE  URETER  519 

opposite  kidney  is  normal,  the  accident  may  never  be  recognized.  On 
the  other  hand,  even  if  both  ureters  are  tied  off,  the  complete  anuria 
which  results  is  symptomless  up  to  the  last  moment,  like  calculous 
anuria. 

2.  If  the  ureter  is  divided  and  the  accident  passes  unrecognized,  the 
position  of  the  wound  is  usually  such  that  the  urine  discharges  into 
the  vagina  and  a  uterovaginal  fistula  remains  to  be  dealt  with. 

3.  If  the  wound  is  so  situated  that  the  urine  is  extravasated  within 
the  peritoneal  cavity,  it  sets  up  peritonitis,  immediate  and  general  if 
the  urine  is  bacterial,  remote  and  localized  if  the  urine  is  clean.  The 
source  of  the  infection  is  suspected  only  when  urine  is  discovered  in 
the  discharge. 

Treatment. — In  the  early  days  of  pelvic  surgery  nephrectomy  was 
the  only  alternative  offered  to  those  women  who  were  left  with  uretero- 
vaginal  fistulae  after  hysterectomy.  But  in  1886  Schopf,  Fritsch,  and 
Tauffer  (twice)  each  recognized  at  the  time  of  operation  that  he  had 
divided  the  ureter  and  proceeded  to  sew  the  ends  together.  Thus  began 
the  conservative  surgery  of  the  ureter,  and  thus  from  the  mishaps  of 
gynecology  has  arisen  the  most  brilliant  conservative  achievement  of  uri- 
nary surgery,  the  preservation  of  the  healthy  kidney  whose  duct  has 
been  severed. 

The  modern  treatment  consists  of  ureteral  anastomosis,  or,  if  that 
is  impossible,  nephrostomy  if  the  condition  of  the  opposite  kidney  is 
indetermined ;  nephrectomy  if  it  is  known  to  be  adequate. 


CHAPTER  LIV 
WOUNDS  AND  EUPTURES  OP  THE  BLADDER  AND  URETHRA 

WOUNDS  OF  THE  BLADDER 

Wounds  of  the  bladder  are  not  common,  since  the  position  of  the 
organ  protects  it  from  ordinary  accidents,  inclosed  as  it  is,  when  in  a 
state  of  relaxation,  by  the  bony  pelvis.  Excepting  the  violence  done  by 
cystoscopes,  lithotrites,  or  during  other  operations,  the  bladder  is  but 
little  liable  to  injury  except  when  overdistended.  Eising  above  the 
symphysis  pubis  it  becomes  exposed  to  incised,  punctured,  and  gun- 
shot wounds.  Wounds  of  the  bladder  are  exceedingly  dangerous  to 
life  without  being  necessarily  fatal.  Bullets  and  fragments  of  shell 
have  entered  the  bladder  without  producing  fatal  consequences,^  and 
there  formed  nuclei  for  calculus,  as  have  also  portions  of  bone.  Surgi- 
cal wounds  aside,  Bartels  ^  was  unable  to  find  among  405  reported 
wounds  of  the  bladder  any  incised  wound.  Lacerations  of  the  bladder 
not  communicating  with  the  external  wound  are,  clinically,  ruptures. 

Symptoms  and  Prognosis. — The  symptoms  of  wounds  of  the  blad- 
der are  comparable  to  those  of  rupture  (plus  an  external  wound).  The 
prognosis  depends  upon  the  presence  and  severity  of  the  complications, 
the  availability  of  surgical  assistance,  and  the  position  of  the  rupture, 
whether  it  is  intraperitoneal  or  extraperitoneal.  Bartels  collected  131 
cases  of  intraperitoneal  wounds,  of  which  only  1  survived,  while  of  373 
extraperitoneal  wounds  only  85  died.  These  statistics  belong  to  the 
preantiseptic  period. 

Evans  and  Fowler  ^  have  collected  25  cases  reported  since  1877,  of 
which  7  were  intraperitoneal  injuries  with  2  deaths,  and  18  extraperi- 
toneal with  2  deaths. 

Treatment, — The  treatment  is  immediate  incision,  suture  of  the 
bladder,  and  packing  of  the  external  wound  to  prevent  infection  and  sec- 
ondary infiltration.  If  the  case  is  not  seen  until  infiltration  has  set  in, 
wide  incisions,  irrigation,  and  drainage  are  necessary. 

^  I  have  recorded  in  the  New  Yorlc  Journal  of  Medicine,  May,  1865,  the  case  of 
an  adult  whose  bladder  was  perforated  by  a  bullet  during  the  New  York  riots  in 
July,  1863,  terminating  in  complete  recovery. — Van  Bueen. 

■'  Arch.  f.  klin.  CUr.,  1877,  xxii,  519,  715. 

''Ann.  Surg.,  1905,  xlii,  215. 

520 


RUPTURE  OF  THE  BLADDER  521 


RUPTURE  OF  THE  BLADDER 


A  bladder,  when  overdistended  by  urine,  may  be  ruptured  by  ex- 
ternal violence,  and  this  especially  if  it  be  atrophied  or  thinned  by  dis- 
ease, ulceration,  or  otherwise ;  or  the  accident  may  occasionally  happen 
by  the  accumulation  of  urine  alone  without  any  recognizable  external 
violence,  as  in  case  of  stricture.  Such  a  spontaneous  rupture  is  un- 
doubtedly attributable  to  muscular  contraction. 

Among  the  exciting  traumatic  causes,  falls,  blows,  and  crushing  in- 
juries, with  or  without  fracture  of  the  pelvis,  or  even  appreciable  injury 
to  the  soft  parts,  may  be  mentioned.  The  patient  is  usually  intoxicated 
at  the  time  of  injury,  the  alcohol  predisposing  him  to  rupture  of  the 
bladder  in  a  threefold  way — viz.,  by  causing  the  bladder  to  fill  rapidly, 
by  obtunding  its  sensibility,  and  by  facilitating  the  injury.  Intraperi- 
toneal rupture  without  known  trauma  has  been  several  times  reported. 
I  have  seen  such  a  case ;  the  patient  was  entirely  sober. 

Suhperitoneal  rupture,  in  which  the  fundus  of  the  bladder  is  torn 
without  lacerating  the  peritoneum,  need  not  be  distinguished,  for  it 
either  remains  extraperitoneal  or  becomes  intraperitoneal. 

Intraperitoneal  rupture  is  the  more  frequent  variety.  It  is  caused 
by  a  blow  upon  the  hypogastrium  bursting  the  distended  organ  as  a  blow 
bursts  a  paper  bag.  There  are  often  no  associated  lesions.  It  has  been 
surmised  that  the  fundus  yields  to  the  distending  force  not  through 
any  weakness  of  the  bladder  at  that  point,  but  because  the  intestines 
give  way  before  it,  while  below  the  bladder  is  supported  by  the  bony 
pelvis. 

Extraperitoneal  rupture  is  almost  always  associated  with  fracture  of 
the  pelvis.     . 

Mitchell  ^  has  collected  90  cases,  of  which  36  per  cent  occurred  on 
the  anterior  surface,  and  most  of  the  others  about  the  neck.  Rupture  of 
the  sides  or  base  is  commonly  intraperitoneal. 

Rupture  of  the  empty  bladder  is  extremely  rare,  always  extraperi- 
toneal, and  due  to  fracture  of  the  pelvis. 

Rupture  of  the  bladder  from  overdistention  preliminary  to  cys- 
totomy has  been  reported  10  times. ^  This  accident  is  always  avoided  if 
the  bladder  is  distended  after  incision  of  the  parietes. 

Results — Peritonitis  is  the  almost  inevitable  outcome  of  intraperi- 
toneal rupture.  As  a  rule,  the  urine  is  infected  and  the  peritonitis  im- 
mediate. But  if  the  urine  is  aseptic  this  peritonitis  may  be  delayed 
several  days ;  may  even  fail  to  appear  altogether  if  the  amount  of  urine 
extravasated  be  small. 

^  Ann.  Surg.,  1898,  xxvii,  151. 

*  Horwitz,  Ann.  Surg.,  December,  1905. 


522      WOUNDS  AND  RUPTURES  OF  BLADDER  AND  URETHRA 

Extraperitoneal  rupture  results  in  cellulitis  and  suppuration  about 
tlie  bladder.     Peritonitis  may  result  as  a  secondary  complication. 

Complications. — Fracture  of  the  pelvis  can  scarcely  be  termed  a 
complication  of  rupture  of  the  bladder.  The  bladder  lesion  is  the 
complication,  since  it  results  from  the  disintegration  of  the  pelvic  ring. 
In  such  cases  the  bladder  rupture  is  usually  extraperitoneal. 

Rupture  of  the  membranous  urethra  is  sometimes  associated  with 
rupture  of  the  bladder  as  a  complication  of  pelvic  fracture. 

Symptoms. — All  the  symptoms  of  rupture  of  the  bladder  may  be  ab- 
sent in  a  given  case,  or  obscured  by  symptoms  due  to  other  injuries. 

The  symptoms  of  a  classical  case  have  been  well  summarized  by  Bes- 
ley,^  as  follows: 

1.  At  the  time  of  the  injury  there  is  immediate  severe  pain  in  the  abdomen, 
and  sometimes  a  distinct  sense  of  something  tearing  or  gi\"ing  way.  This  is 
described  by  the  patient  as  being  in  the  lower  part  of  the  abdomen,  or  occa- 
sionally referred  to  the  region  of  the  heart.  The  severe  pain  felt  at  the  outset 
is  usually  continuous.  Marked  symptoms  and  signs  of  collapse  are  quite 
constantly  found.  .  .  . 

2.  The  patient  is  unable  to  walk,  or  walks  with  great  difficulty.  Records 
of  eases  show  this  to  be  an  almost  constant  condition. 

3.  One  of  the  most  prominent  and  constantly  present  symptoms  is  the 
strong  desire,  accompanied  with  an  inability,  to  void  uritie.  A  few  drops  of 
blood  or  bloody  urine  usually  pass  from  the  urethra.  Not  infrequently,  how- 
ever, the  patients  are  able  to  void  urine  in  either  an  extraperitoneal  or  an 
intraperitoneal  rupture.  Bloody  urine  was  a  marked  sign  in  every  ease  of 
this  report. 

4.  The  subsequent  course  of  the  disease  and  the  symptoms  depend  upon  the 
location  of  the  rupture  and  the  direction  of  the  extravasation. 

If  the  tear  is  intraperitoneal,  the  course  will  be  that  of  a  peritonitis  with 
obstipation,  vomiting,  and  high  pulse  and  temperature.  It  must  be  borne  in 
mind  that  the  temperature  curve  is  only  one  item,  and  the  presence  or  absence 
of  fever  is  not  absolutely  diagnostic  for  or  against  a  peritonitis. 

When  the  rupture  is  extraperitoneal,  the  symptoms  are  those  due  to  an 
extravasation  of  the  urine  into  the  tissues,  giving  rise  to  the  absorption  of 
the  poisonous  properties  of  the  urine  and  the  toxins  of  the  accompanying 
suppuration. 

These  symptoms  are  those  of  sepsis,  with  chills,  high  pulse,  irregular 
temperature   curve,   headache,   and  gastro-intestinal   disturbances. 

Diagnosis — Rupture  of  the  bladder  may  be  suspected  when  a  pa- 
tient has  received  a  contusion  of  the  hypogastrium  or  a  fracture  of  the 
pelvis  and  thereafter  either  passes  bloody  urine  or  no  urine  at  all ;  when 
a  patient  in  alcoholic  stupor  shows  undue  rigidity  and  tenderness  about 
the  hypogastrium  and  catheterism  draws  no  urine  or  bloody  urine ;  when 
a  patient  known  to  suffer  from  a  grave  bladder  lesion  complains  of  sud- 
den severe  hypogastric  pain  and  thereafter  strives  in  vain  to  urinate; 
and  when  there  is  fracture  of  the  pelvis. 

^8v/rgery,  Gyn.,  and  Obstet.,  1907,  iv,  514. 


RUPTURE  OF  THE  BLADDER  523 

The  diagnosis  is  verified  by  a  study  of  the  symptoms  aided  by  pal- 
pation, urethral  instrumentation,  and,  if  necessary,  by  exploratory  op- 
eration. 

Palpation.- — At  the  outset,  palpation  of  the  hypogastrium  reveals 
rigidity  and  tenderness  (which  may,  however,  be  due  to  parietal  contu- 
sion). Later  the  space  of  Retzius  may  be  filled  by  a  doughy  sensitive 
infiltrate  (extraperitoneal  rupture)  or  the  rigidity  and  tenderness  may 
extend  to  the  whole  abdomen  (intraperitoneal  rupture). 

If  the  rupture  is  extraperitoneal  rectal  palpation  may  reveal  ten- 
derness and  infiltration. 

Catheteeism. — The  catheter  usually  withdraws  a  little  bloody 
urine.  Exceptionally  a  large  amount  of  urine  is  obtained  that  shows 
blood  only  to  the  miscroscope. 

If  catheterism  is  impossible  because  of  ruptured  urethra,  immediate 
perineal  section  should  be  performed. 

Injection  Tests. — Injection  of  air  may  increase  the  shock,  and  is 
therefore  condemned. 

Injection  of  a  measured  quantity  of  salt  solution,  to  see  whether  it 
all  returns,  may  be  employed  in  doubtful  subacute  cases ;  but  this  test 
is  far  from  infallible.  If  the  rupture  is  small  or  valvelike  all  the  fluid 
may  return. 

Moreover,  the  surgeon  should  be  prepared  to  follow  up  the  examina- 
tion by  immediate  operation  if  rupture  is  discovered,  since  this  instru- 
mentation is  calculated  to  spread  urine  and  infection  broadcast  through- 
out the  peritoneum  or  the  cellular  tissues. 

Hence,  recent  writers  follow  Alexander  ^  in  condemning  this  test. 

If  the  diagTiosis  is  obscure  it  may  be  verified  by  cystoscopy.  I  was 
thus  able  to  diagnose  a  bullet  wound  of  the  bladder. 

ExPLORATOKY  OPERATION. — If  there  is  still  doubt,  the  abdomen 
should  be  opened  in  the  median  line,  and  the  peritoneum  opened. 
Palpation  then  detects  any  infiltration  about  the  base  of  the  bladder. 

Treatment. — When  the  diagnosis  is  established  there  is  no  treat- 
ment other  than  immediate  operation;  when  it  is  in  doubt  an  explora- 
tory operation  affords  the  quickest  and  surest  means  of  reaching  a 
conclusion  that  must  be  reached  quickly  if  at  all.  The  only  contra- 
indications to  operation  are  shock  and  grave  visceral  injuries,  and  if  an 
infusion  of  salt  solution  improves  the  general  condition  the  operation 
should  be  performed  even  in  shock. 

The  first  incision  should  open  the  peritoneal  cavity  through  the 
median  line.  If  an  intraperitoneal  tear  is  encountered,  it  is  closed 
with  a  layer  of  Lembert  sutures  in  the  bladder  wall,  and  another  in  the 
peritoneum.  AJl  accumulations  of  fluid  are  gently  mopped  up.  Mean- 
while the  strength  of  the  suture  line  is  tested  by  filling  the  bladder 

^Ann.  Surg.,  1901,  xxxiv,  209, 


524   WOUNDS  AND  RUPTURES  OF  BLADDER  AND  URETHRA 

with  salt  solution.  If  any  escapes,  the  leaky  portion  of  the  wound 
is  protected  by  additional  sutures.  This  test  is  most  essential.  In  4 
cases  mentioned  by  Walsham  ^  the  cause  of  death  was  leakage  through 
the  sutured  bladder  wound.  The  abdominal  wound  is  then  closed  with 
a  single  wick  of  gauze  running  to  the  point  of  rupture. 

If  the  peritoneum  proves  to  be  untorn,  the  abdominal  wound  is 
closed  and  the  bladder  opened  through  a  small  suprapubic  incision.  If 
the  hole  in  the  bladder  is  found  presenting,  it  is  sutured,  tested,  and 
the  external  wound  drained.  But  if  the  rupture  is  situated  at  the 
bladder  neck  or  at  some  other  inaccessible  point,  it  may  be  treated  by 
suture  or  left  untouched,  and  drainage  may  be  established  through 
the  abdominal  wall  and  the  urethra  or  the  perineum. 

Prognosis.— Among  Mitchell's  90  cases  of  extraperitoneal  rupture 
of  the  bladder  37  were  operated  upon  and  24  of  these  died  (64.9  per 
cent)  ;  while  of  the  53  treated  expectantly  51  died  (96.2  per  cent). 
Sieur  ^  collected  34  cases  of  intraperitoneal  rupture,  all  operated  upon, 
with  the  following  results : 


Operation. 

Cases. 

Cured. 

Died. 

Mortality. 

Within  12  hours 

13 
10 
11 

8 
3 
3 

5 

7 
8 

38 . 4  per  cent. 

12  to  24  hours 

70 

24  to  62  hours 

72.7 

Total            

34 

14 

20 

58.8 

Without  operation  practically  all  would  have  died. 

These  statistics  encourage  early  operation  so  markedly  as  to  call  for 
no  comment.  Doubtless  the  relatively  low  postoperative  mortality  of 
intraperitoneal  (58.5  per  cent),^  as  compared  to  extraperitoneal  rupture 
(64.9  per  cent),  may  be  due  to  the  fact  that  the  immediate  gravity  of 
the  peritoneal  cases  enforces  early  operation,  while  the  slower  progress 
of  extraperitoneal  ruptures  encourage  ill-advised  delay. 


WOUNDS  OF  THE  URETHRA 


The  urethra  may  be  wounded  by  traumatism  from  within  or  from 
without.  External  wounds  only  concern  us  here.  Internal  wounds, 
whether  produced  by  foreign  bodies,  by  instrumentation,  or  by  internal 
urethrotom}-,  find  more  appropriate  exposition  under  their  respective 
titles. 

^Univ.  Med.  Jour.,  1S95,  iii,  200. 

^  ArcMv  gen.  de  med.,  1894,  i,  129. 

®  Alexander  gives  51.1  per  cent,  Watson,  42.2  per  cent. 


RUPTURE  OF  THE  URETHRA  525 

Punctured  Wounds. — The  prognosis  of  a  punctured  wound  of  the 
urethra  is  generally  good.  For  simple  punctured  wounds  a  single  irri- 
gation of  the  wound  and  the  urethra  with  an  antiseptic  solution  (e.  g., 
permanganate  of  potassium,  1:  4,000),  followed  by  careful  catheteriza- 
tion for  each  urinary  act  during  the  first  one  to  three  days,  should  result 
in  a  cure.  If  the  puncture  is  merely  the  central  point  of  a  laceration  or 
a  contusion  of  the  canal,  the  treatment  must  be  carried  out  as  laid  down 
for  these  conditions.  Complicating  suppuration,  infiltration,  or  fistula 
requires  appropriate  treatment,  as  indicated  below. 

Incised  Wounds. — Clean-cut  wounds  are  very  rare  in  the  peri- 
neum ;  they  usually  implicate  the  penile  urethra,  the  corpus  spongiosum, 
and  often  some  portion  of  the  corpora  cavernosa.  The  complications  to 
be  feared  are  periurethritis,  traumatic  stricture,  and  fistula.  Wounds 
in  the  scrotal  region  are  most  likely  to  be  followed  by  severe  inflamma- 
tion, while  obstinate  fistula  is  the  usual  complication  of  wounds  of  the 
penile  urethra.  The  progiiosis  of  stricture,  on  the  other  hand,  de- 
pends on  the  extent  rather  than  on  the  situation  of  the  lesion.  Stricture 
does  not  follow  longitudinal  wounds  of  the  urethra,  but  results  rapidly 
from  any  transverse  or  oblique  wound.  When  the  anterior  urethra  is 
completely  severed,  the  cut  ends  retract  within  the  corpus  spongiosum  to 
such  an  extent  that  it  may  be  difficult  to  bring  them  together  again. 

Treatment. — Immediate  suture  with  suprapubic  drainage  as  for 
rupture. 

RUPTURE  OF  THE  URETHRA 

This  includes  all  contused  and  lacerated  wounds  of  the  canal  in- 
flicted from  without,  and  is  by  far  the  most  common  urethral  injury,  the 
lesion  usually  involving  the  bulb,  rarely  the  pendulous,  and  still  more 
rarely  the  posterior  urethra. 

Etiology. — 1.  The  pendulous  urethra  is  practically  safe  from  injury 
except  during  erection ;  but  in  that  condition  it  is  liable  not  only  to  ex- 
tensive injury,  as  in  fracture  of  the  penis  and  breaking  a  chordee,  but 
also,  as  Guy  on  insists,  to  slight  tears  by  bruising  during  coitus— injuries 
which,  though  scarcely  noted  at  the  time,  may  have  dire  consequences. 

2.  Rupture  of  the  bulb  is  usually  the  result  of  direct  violence — fall- 
ing astride  of  a  beam  or  some  such  hard  object  (in  82  per  cent — Kauf- 
mann),  a  kick  upon  the  perineum,  or  the  jolting  of  a  rider  onto  the 
pommel  of  his  saddle. 

3.  The  posterior  urethra  is  torn  only  with«.fracture,  dislocation,  or 
severe  strain  of  the  pelvis,  or,  exceptionally,  by  excessive  direct  violence. 
The  membranous  urethra  is  commonly  involved,  being  torn  with  the 
triangiilar  ligament,  while  the  prostatic  urethra  is  spared  in  all  but  the 
most  extensive  fractures. 


526   WOUNDS  AND  RUPTURES  OF  BLADDER  AND  URETHRA 

The  mechanism  of  rupture  of  the  bulb  has  provoked  much  dispute. 
When  the  force  is  applied  obliquely,  the  canal  is  crushed  against  the 
ischiopubic  rami;  when  from  in  front,  as,  for  instance,  in  a  fall  with 
the  body  bent  forward,  the  impact  is  against  the  front  of  the  pubes 
(Oberst,  Terrillon)  ;  while  in  certain  cases,  where  the  force  is  applied 
directly  from  below,  the  urethra  is  probably  torn  at  the  sharp  edge  of 
the  suprapubic  ligament  (Oilier  and  Poncet).  It  is  upon  this  last 
theory  that  differences  of  opinion  persist. 

Pathology — The  trauma  which  ruptures  the  urethra  generally 
spares  the  surrounding  soft  parts.  As  the  injury  is  usually  the  work  of 
a  blunt  implement,  the  skin  and  the  muscles  are  not  torn,  and  the 
superficial  aspect  is,  frequently  enough,  that  of  a  mere  bruise  or  abra- 
sion. 

The  canal  itself  may  be  merely  bruised,  or  more  or  less  completely 
torn  asunder.  In  the  posterior  urethra  complete  laceration  is  the  rule, 
the  canal  being  broken,  as  it  were,  in  the  grip  of  the  triangular  liga- 
ment. In  the  bulb  complete  laceration  through  part  of  the  circumfer- 
ence of  the  canal  is  the  rule ;  but  the  roof  is  usually  spared — a  point  of 
considerable  importance  in  subsequent  catheterization.  In  the  anterior 
urethra  the  milder  injuries  consist  in  mere  interstitial  hemorrhage  ^ — 
contusions,  as  it  were — of  the  corpus  spongiosum,  with  perhaps  slight 
lacerations  of  the  mucous  membrane  or  of  the  sheath  of  the  spongy 
body. 

Symptoms — The  cardinal  symptoms  of  injury  to  the  urethra  are 
pain,  tenderness,  bleeding,  interference  with  urination,  and  tumefac- 
tion. 

The  pain  is  sharp  and  occurs  at  the  moment  of  rupture.  It  may  be 
the  only  symptom  of  interstitial  rupture  due  to  a  jar  to  the  erect  penis. 
As  it  abates  rapidly  the  patient  may  pay  but  little  attention  to  it,  though 
even  a  slight  injury  may  lay  the  foundation  for  traumatic  stricture. 
The  pain  recurs  with  each  act  of  urination  for  a  longer  or  shorter  time, 
according  to  the  gravity  of  the  injury  and  the  temperament  of  the 
person. 

Tenderness  exists  primarily  at  the  point  of  injury  and  later  in  the 
course  of  inflammation. 

Bleeding  from  the  meatus  is  a  constant  symptom.  It  is  lacking  only 
in  the  rare  cases  in  which  the  mucous  membrane  is  uninjured.  It  occurs 
quite  independent  of  urination  (urethrorrhagia),  its  quantity  not  indi- 
cating the  severity  of  the  lesion.  The  unbroken  skin  usually  prevents 
external  hemorrhage,  though  a  hematoma  of  some  size  is  not  unusual. 

*  The  possibility  of  this  condition,  as  well  as  its  clinical  importance,  has  been 
warmly  debated.  Baron  (Presse  med.,  1898,  i,  250)  sums  up  the  evidence  at  hand, 
and  shows  that  a  simple  contusion,  without  any  break  in  the  mucous  membrane,  may 
perfectly  well  be  the  starting-point  for  traumatic  stricture. 


RUPTURE  OF  THE  URETHRA  527 

Hematuria  combined  with  iirethrorrhagia  indicates  an  injury  to  the 
posterior  urethra. 

The  disturbance  of  urination  varies  from  the  hesitancy  excited  by 
the  pain  of  the  milder  cases  to  complete  retention.  This  latter,  indeed, 
is  the  usual  condition,  and  is  due  to  contraction  of  the  lacerated  urethra 
and  to  spasm  of  the  cut-off  muscle,  rarely  to  hematoma  of  the  corpus 
spongiosum.  The  retention,  if  not  speedily  relieved,  is  intensified  by 
the  congestion  and  inflammation  about  the  wound. 

Tumefaction,  primarily  the  efl^ect  of  hemorrhage,  secondarily  of  uri- 
nary infiltration  and  suppuration,  follows  the  fascial  spaces.  The  tumor 
after  injury  to  the  pendulous  urethra  is  usually  a  circumscribed  one 
within  the  corpus  spongiosum,  but  may  follow  the  course  of  a  perineal 
infiltration  and  extend  throughout  the  scrotum  and  penis.  Effusions 
within  the  triangular  ligament  are  retained  there  to  form  a  tense  peri- 
neal tumor,  which  may  burst  either  forward  or  backward,  while  injury 
to  the  prostatic  urethra  leads  to  infiltration  of  the  rectovesical  space. 

Diagnosis. — The  diagnosis  of  the  extent  of  injury  is  not  easy.  Im- 
mediate interference  with  urination,  which  always  follows  complete  rup- 
ture, may  be  caused  by  spasm  or  by  retained  clots.  Catheterization, 
impossible  if  there  is  complete  rupture,  may  fail  even  in  milder  cases. 
It  is  sufficient,  however,  for  practical  purposes,  to  diagnose  the  severity 
of  the  case  according  to  the  symptoms,  as  indicated  below.  Diagnosis 
of  the  position  of  the  injury  may  be  made  with  a  fair  degree  of  accuracy 
from  its  etiology  and  the  location  of  the  tenderness  and  tumor.  The 
presence  of  urethrorrhagia,  while  establishing  the  existence  of  rupture 
of  the  urethra,  does  not  exclude  rupture  of  the  bladder ;  but  a  positive 
diagnosis  of  the  latter  condition  is  usually  practicable. 

Course  and  Prognosis — Guyon's  classification  is  convenient  as  offer- 
ing the  most  precise  indications  for  treatment.    It  is  as  follows : 

1.  Mild  injuries  to  the  pendulous  urethra,  in  which  the  trauma  is 
succeeded  by  a  sharp  pain,  slight  bleeding,  and  a  few  painful  urinary 
acts,  are  not  likely  to  be  followed  by  any  serious  consequences,  except 
traumatic  stricturCj  which  is  almost  inevitable. 

2.  Moderately  severe  injuries  to  the  pendulous  urethra  are  charac 
terized  by  free  bleeding,  painful  and  impeded  urination,  and  a  hema- 
toma of  some  size.  The  chief  danger  here  lies  in  infiltration  and  peri- 
urethral suppuration  and  later  traumatic  stricture. 

3.  In  the  severe  injuries  and  in  most  perineal  cases  complete  reten- 
tion is  the  prominent  symptom.  It  can  rarely  be  relieved  otherwise 
than  by  external  urethrotomy. 

In  any  case  traumatic  stricture  may  be  predicted — a  condition  for- 
midable both  in  its  rapidity  of  onset  and  its  rebelliousness  to  treatment 
(See  Chapter  XXVII). 

The  mortality  from  rupture  of  the  urethra  is  low.    Terrillon  records 


528   WOUNDS  AKD  RUPTURES  OF  BLADDER  AND  URETHRA 

12  deaths  in  170  cases,  chiefly  from  uremia,  septicemia,  and  hemor- 
rhage. 

Treatment. — l.  For  mild  injuries  to  the  petidulous  urethra  expect- 
ant treatment  should  be  employed.  Eest  in  bed,  free  purgation,  and  the 
internal  administration  of  hexamethylenamin  should  be  supplemented 
by  injection  twice  a  day  of  3  to  5  c.c.  of  silver  nitrate  solution  (1: 
2,000)  or  protargol  (1:  1,000)  into  the  anterior  urethra.  Catheteriza- 
tion is  unnecessary  and  absolutely  contra-indicated.  Extravasation  or 
suppuration  must  be  met  by  prompt  incision.  Three  days  after  the 
symptoms  have  subsided  the  patient  may  be  pronounced  free  from  all 
dangers  except  stricture,  against  which  he  must  be  warned,  and  for 
which  treatment  is  to  be  instituted  on  its  appearance.  The  contraction 
usually  begins  within  six  weeks  of  the  time  of  injury. 

2.  Moderately  severe  anterior  injuries  represent,  in  a  general  way, 
slight  lacerations,  in  which  one  may  hope  to  avoid  infiltration  by  keep- 
ing the  urethra  cleansed,  as  above,  and  preventing  any  contact  of  the 
urine  with  the  wound.  A  small  (15  French)  rubber  catheter  should 
be  tied  in. 

3.  Perineal  ruptures  and  all  severe  injuries  to  the  pendulous  ure- 
thra call  for  immediate  external  urethrotomy  and  suture.  Palliative 
measures,  such  as  suprapubic  aspiration,  catheterization,  or  the  retained 
catheter,  cannot  save  the  day.  Aspiration  may  be  useful  to  relieve  the 
distention  of  the  bladder  and  thus  to  gain  time,  but  the  retained  catheter 
is  worse  than  useless.  It  serves  only  to  invite  infiltration,  while  re- 
peated catheterization  is  impossible  as  soon  as  congestion  sets  in.  On 
the  other  hand,  perineal  section  relieves  the  retention  at  once,  while 
suture  of  the  divided  ends  of  the  urethra  affords  the  surest  means  of 
preventing  resilient  traumatic  stricture. 

Marion  -^  very  properly  insists  upon  the  great  advantage  of  deflect- 
ing the  urinary  stream  through  a  suprapubic  fistula.  He  performs  this 
first,  does  retrograde  catheterization  if  necessary  and  sutures  the  urethra 
about  a  catheter.  The  perineal  wound  is  left  open.  He  reports  10 
cases  with  no  subsequent  stricture. 


URETHRORECTAL  FISTULAE 

Urethrorectal  fistulae  are  very  rare.  They  commonly  arise  from  the 
prostatic  urethra.  They  are  caused  by  trauma  (usually  surgical),  ab- 
scess of  the  prostate,  tuberculosis,  or  malignant  disease.  Tuberculous 
and  cancerous  fistulae  are  quite  incurable  and  need  not  concern  us. 
Traumatic  and  inflammatory  fistulae,  on  the  other  hand,  commonly 
recover.     I  once  opened  a  prostatic  abscess  into  the  rectum  only  to 

^Jour.  d'Vrol,  1914,  v,  553. 


URETHRORECTAL  FISTULAE  529 

find  that  it  had  just  burst  into  the  bladder.  The  resultant  fistula 
healed  in  four  weeks.  I  have  thrice  opened  the  rectum  during  pros- 
tatectomy. Each  time  the  fistula  healed  spontaneously.  But  the 
fistula  that  does  not  heal  in  three  months  will  never  heal  spontaneously. 
Treatment. — Cases  that  do  not  recover  spontaneously  require  opera- 
tive interference  unless  they  are  so  slight  that  they  cause  the  patient 
no  material  discomfort.  The  healing  of  these  fistulae  is  an  exceedingly 
difficult  task.  One  can  not  guarantee  that  the  operation  will  not  leave 
the  patient  in  a  worse  condition  than  before. 


CHAPTER   LV 

MALFORMATIONS  OF  THE  KIDNEY  AND  URETER 

The  malformations  of  the  kidney  and  the  ureter  are  explicable 
in  terms  of  the  embryological  development  and  migrations  of  these  or- 
gans. Charles  Mayo  ^  has  summed  up  the  essentials  of  the  embryology 
of  the  kidney  in  so  far  as  it  bears  upon  the  malformations  of  the 
kidney  and  the  ureter  as  follows : 

The  kidney-secreting  substance  extends  as  mesothelial  bodies  or  nephrogenic 
tissue  from  the  lower  dorsal  to  the  second  sacral  vertebra.  They  lie  close 
together  with  the  aorta  between.  This  substance  is  supplied  by  many  blood- 
vessels derived  from  a  delicate  plexus  surrounding  and  connecting  with  the 
aorta.  From  a  pouch  which  early  appears  from  the  lower  portion  of  the 
wolffian  duct  are  developed  the  ureter  and  pelvis  of  the  kidney.  This  col- 
lecting portion  becomes  attached  to  the  secreting  portion  by  climbing  up  the 
ladder  of  the  blood  supply,  so  to  speak,  of  the  nephrogenic  substance.  The 
numerous  blood  vessels  drop  off  and  enlarge  as  the  pelvis  of  the  kidney  ascends 
to  its  higher  position,  and  the  secreting  substance  an-anges  itself  over  it  and 
forms  a  cajDsule.  The  two  mesothelial  bodies  may  touch  each  other  and  become 
fused,  developing  the  horseshoe  kidney  or  various  attachments;  90  per  cent 
of  the  horseshoe  kidneys  being  fused  at  the  lower  pole.  Some  of  the 
mesothelial  or  secreting  portion  of  the  kidney  may  not  become  connected  with 
the  collecting  portion  and  maj'  then  retain  its  embryonic  type,  forming  a 
mesothelial  rest  from  which  may  develop  so-called  "hj^pernephroma"  or,  more 
correctly,  mesothelioma  of  the  kidney  (Wilson).  In  other  cases  a  failure  of 
connection  between  the  secreting  portion  with  the  collecting  ca\aty  and  con- 
tinuance of  secretion  without  elimination  form  a  congenital  cystic  kidney, 
usually  double. 

Wherever  the  kidney  stoj^s  in  the  process  of  union  of  collecting  and 
secreting  portions,  its  renal  artery  develops  from  the  major  supplying  it  at 
the  time.  As  growth  continues,  the  delicate  vascular  plexus  outside  the  aorta 
disappears  and  the  renal  arteiy  comes  directly  from  the  aorta;  but  owing  to 
change  in  position  it  may  come  from  a  lower  position  on  the  aorta,  the  sacral 
artery  or  from  the  common  iliac.  The  malposition  of  the  kidney  is  not  so 
serious  if  it  can  but  carry  on  its  function,  but  malposition  may  lead  to  injury. 
Excessive  mobility  is  not  a  disease  unless  the  renal  function  is  interfered  with 
or  the  kidney  in  its  movements  disturbs  some  other  organ ;  thus  the  movable 
right  kidney  may  disturb  a  diseased  appendix,  Ihe  appendix,  however,  being 
the  primary  offender.  Mobility  may  interfere  with  urinary  delivery  by  kinking 
the  ureter  over  a  band  of  connective  tissue  or  an  anomalous  artery  which 
occasionally  is  seen  connecting  the  lower  pole  of  the  kidney  with  the  aorta, 
one  of  the  original  mesothelial  vessels  which  failed  to  disappear.     One  kidney 

^Surg.,  Gyn.  4-  Ohstet.,  1916,  xxii,  16. 

530 


MALFORMATION  OF  THE  KIDNEY  531 

may  be  missing  from  a  failnre  of  development  of  the  mesothelimn — the  secret- 
ing structure.  Three  or  four  kidneys  may  be  present  with  three  or  four  com- 
plete ureters  or  partial  ureters.  Splitting  the  collecting  portion  at  the  wolffian 
duct  causes  double  ureters  and  fused  or  separated  double  kidneys  on  one  or 
both  sides.  The  division  of  the  pelvis  into  several  tubes  connecting  with  one 
or  two  ureters  is  normal  in  the  otter  and  beaver. 


MALFORMATION  OF   THE  KIDNEY 


Frequency.- — Abnormalities  of  the  kidney  are  very  rare.  Morris* 
has  collected  the  records  of  11,168  post  mortem  examinations  at  the 
Middlesex  Hospital  and  Guy's.  Excluding  movable  kidneys,  16  cases 
of  double  ureter,  and  53  cases  of  acquired  atrophy  and  small  cirrhotic 
kidney,  his  cases  may  be  tabulated  thus: 

Congenital  atrophy   (unilateral) 11  eases. 

Fused  kidney 1  case. 

Horseshoe  kidney 16  cases. 

Lobulated  kidney  (4  bilateral) 9  cases. 

Malformed  kidney   (1  bilateral) 6  cases. 

Misplaced  kidney 10  cases. 

About  1  case  in  211. 

Motzfeldt  -  found  79  cases  of  deformity  of  some  kind  at  4,500 
necropsies,  including  9  of  horseshoe  kidney;  double  ureters  in  23; 
hydronephrosis  in  21;  aplasia  in  10,  and  hypoplasia  in  11 — a  total  of 
deformities  of  some  kind  in  the  urinary  apparatus  in  2  per  cent  of  all 
the  cadavers.  One  of  the  kidneys  was  abnormally  small  in  22  cases ;  the 
other  was  hypertrophied  in  a  few  instances. 

CONGENITAL  MALFORMATIONS 

Malformation  Without  Fusion — Most  of  the  malformations  with- 
out fusion  are  unimportant.  Fetal  lobulation  may  persist  in  part  or 
in  the  whole  of  a  kidney  throughout  life.  Simple  hypertrophy  of  a  kid- 
ney is  usually  compensatory  to  the  atrophy  of  its  fellow.  ■  IsTeither  of 
these  present  any  surgical  interest  excepting  that  the  latter  may  be 
mistaken  for  tumor.  The  misplaced  kidney  may  be  deformed  by  the 
pressure  of  tlie  surrounding  viscera.  Movable  kidneys  may  assume 
very  curious  shapes.  Considerable  malformation  of  the  kidney  is  usu- 
ally associated  with  misplacement  and  is  of  interest  in  that  con- 
nection. 

Congenital  Atrophy— Extreme  atrophy  of  the  kidney  of  congenital 

^"Surgical  Diseases  of  the  Kidney  and  Ureter,"  1901,  i,  32. 
'Norsk.  Mag.  f.  Laeg.,  1914,  Ixxv,  No.  7. 


532 


MALFORMATIONS  OF  THE  KIDNEY  AND  URETER 


origin  is  extremely  rare.  Geraghty  and  Plaggemeyer  ^  find  that  the 
estimates  vary  from  1  in  110  to  1  in  3,993  cases.  The  disagreement 
is  due  to  the  variation  in  what  the  observer  is  willing  to  accept  as  an 
atrophied  kidney.  Partial  congenital  atrophy  or  smallness  of  a  kidney 
is  not  infrequent.  I  have  encountered  it  three  times  in  operating  upon 
186  kidneys.  The  condition  is  of  the  utmost  surgical  importance 
because  the  small  kidney  may  be  entirely  normal  and  yet  not  possess 


Fig.  110. — Congenital  Kidney  Atrophy;  Stone  in  Pelvis;  Pyelitis  Cystica. 


sufficient  kidney  tissue  to  support  life,  while  its  fellow  may  be  dis- 
eased and  require  nephrectomy.  Unless  care  is  taken  in  the  ureter 
catheter  diagTiosis  the  fact  that  the  healthy  kidney  is  putting  out  but 
a  small  quantity  of  urine  may  be  overlooked.  Geraghty  called  attention 
to  this  fact  and  gave  a  formula  for  the  recognition  of  the  condition 
(which,  of  course,  applies  to  acquired  as  well  as  congenital  atrophy). 
Their  formula,  as  applied  to  the  healthy  kidney,  is  the  following: 

The  amount  of  urine  excreted  is  small.  Therefore,  though  the 
percentage  of  urea  is  normal,  the  total  urea  is  diminished.  The  phenol- 
sulphonephthalein  output  is  also  diminished.  By  the  use  of  this  for- 
mula, I  was  able  to  diagnose  atrophy  in  the  kidney  shown  in  Fig.  110. 

*  Trans.  Am.  Assn.  G.-TJ.  Surg.,  1913,  viii,  48. 


MALFORMATION  OF  THE  KIDNEY  533 

The  x-raj  had  previously  shown  the  stone;  the  cystoscope  revealed  a 
very  small  middle  lobe  of  the  prostate;  ureter  catheters  were  readily 
introduced  on  both  sides,  and  there  was  no  extra-catheter  flow.  The 
urine  from  the  right  kidney  showed  a  few  pus  cells,  1.2  per  cent  urea, 
phenolsulphonephthalein  7  per  cent  in  2  c.c.  (after  a  delay  of  10 
minutes  in  its  appearance).  The  left  kidney  gave  no  pus,  urea  1.3  per 
cent,  25  per  cent  phenolsulphonephthalein  in  8  c.c. 

Anomalies  of  the  Blood  Vessels — Eupert^  in  a  recent  review  of 
this  subject,  chiefly  founded  on  a  personal  study  of  118  cadavers, 
found  among  the  236  kidneys  examined  77  arterial  and  26  venous  ab- 
normalities. Fortunately,  however,  the  surgeon  does  not  require  to 
make  an  intimate  study  of  these  variations,  but  simply  must  know  that 
they  are  extremely  common.  In  the  normal  kidney  the  main  artery 
and  vein  may  be  double,  and  may  not  arise  directly  from  the  trunk 
vessels.  Moreover,  accessory  arteries  and  veins  may  run  to  the  upper 
or  lower  poles.  The  careful  surgeon  will,  therefore,  always  palpate  any 
bundle  of  rather  thick  tissue  or  adherent  substance  at  either  pole  of 
the  kidney  before  cutting  this.  If  the  pulsation  of  an  artery  is  felt  in 
it  this  will  be  spared  if  possible,  for  the  renal  arteries  are,  to  all 
intents  and  purposes,  terminal.  If  no  pulsation  is  felt  the  band  of 
tissue  will  be  separated  gently,  and  if  a  vein  is  found  or  accidentally 
torn  this  will  simply  be  ligated,  for  venous  anastomoses  within  the  kid- 
ney are  plentiful. 

Animal  experimentation  would  seem  to  suggest  that  the  renal 
arteries  are  not  strictly  terminal,  but  are  provided  with  anastomosing 
capillaries  so  extremely  small  that  they  escape  injection  by  the  ordinary 
methods   (Liek^). 

The  displaced  or  malformed  kidney  usually  has  a  number  of  ir- 
regular arteries  and  veins  arising,  as  suggested  above,  from  adjacent 
portions  of  the  great  vessels. 

The  Misplaced  Kidney — The  misplaced,  dystopic  or  pelvic  kidney 
is  totally  different  from  the  movable  kidney.  The  latter  has  reached 
its  normal  position  at  the  loin,  but  has  a  long  pedicle  and  a  certain 
degree  of  mobility  within  the  loin.  The  misplaced  kidney  has  never 
reached  its  normal  position,  and  is  fixed  in  an  abnormal  one. 

The  following  data  are  derived  chiefly  from  the  contribution  of 
Plummer  :^ 

Whereas  the  movable  kidney  is  usually  on  the  right  side,  the  mis- 
placed kidney  is  usually  on  the  left  side.  The  misplaced  kidney  may  be 
found  either  within  the  small  pelvis  or  in  the  region  of  the  promontory 
of  the  sacrum.     The  majority  of  misplaced  kidneys  are  not  single  kid- 

^Surg.,  Gyn.  tj'-  Obstet.,  1915,  xxi,  471. 
^Arch.  f.  liin.  Chir.,  1915,  cvi,  485. 
^Surg.,  Gyn.  N  Obstet.,  1913,  x\'i,  1. 


534 


MALFORMATIONS  OF  THE  KIDNEY  AND  URETER 


neys  but  the  majority  of  single  or  fused  kidneys  are  misplaced.  Of 
Strater's  cases,  12  were  bydronephrotic,  6  pyonephrotic.  He  also  noted 
stone,  sarcoma,  tuberculosis  and  cystic  disease. 

Many  misplaced  kidneys  function  perfectly  well  during  life,  and 
are  found  at  autopsy.  Tbey  may  themselves  become  diseased,  in  which 
case  they  give  the  symptoms  of  the  disease  with  which  they  are 
afflicted,  but  the  most  frequent  way  in  which  they  arouse  surgical  in- 
terest is  by  their  interference  with  pregnancy.  The  pregnant  uterus, 
pressing  upon  the  misplaced  kidney,  is  very  likely  to  cause  acute  reten- 
tion or  infection,  or,  on  the 
other  hand,  if  the  kidney  is 
sufficiently  diseased  to  be- 
come a  large  mass,  it  may  ac- 
tually impede  the  progress  of 
pregTiancy.  It  is  alleged  that 
a  feeling  of  weight  and  pain 
in  the  lower  abdomen,  dys- 
pareunia  and  disturbances  of 
the  function  of  the  bladder 
and  rectum  may  result  from 
the  misplaced  kidney.  Mis- 
placement of  the  kidney  will 
be  suspected  whenever  preg- 
nancy is  interfered  with  by 
an  obscure  abdominal  growth, 
or  when  the  symptoms  of  some  renal  disease  are  associated  with  a  mass 
in  the  lower  portion  of  the  belly.  The  condition  can  be  satisfactorily 
diagnosed  only  by  pyelography  as  has  been  beautifully  illustrated  by 
Braasch.^  D.  Bissell  ^  has  been  able  by  careful  dissection  in  three  cases 
to  replace  the  misplaced  kidney  sufficiently  high  in  the  loin  to  insure  the 
three  essentials :  freedom  from  pressure,  good  ureteral  drainage,  and 
good  vascular  supply.  The  operations  were  performed  by  freeing  ad- 
hesions, and  severing  the  smaller  vessels,  both  arteries  and  veins,  notably 
those  going  to  the  lower  pole.  Strater  suggests  that  this  is  the  proper 
treatment  at  the  beginning  of  pregnancy,  but  that  in  the  last  few  months 
premature  labor  should  be  induced,  and  nephrectomy  or  replacement 
performed  later.  Cesarean  section  may  be  necessary.  Cragin  made  a 
vaginal  puncture  of  a  bydronephrotic  kidney.  Fifteen  hours  later  the 
patient  went  through  a  normal  labor. 

The  Fused  and  Horseshoe  Kidney — The  single  kidney  results  from 
atrophy  of,  or  absence  of,  its  fellow  whose  ureter  is  either  entirely  ab- 
sent or  only  partially  developed.     Fusion  of  the  kidney  results  from 
actual  union  of  the  two  kidneys  with  two  or  more  ureters  draining  the 
*" Pyelography,"  1914.  "Trans.  Am.  Gyn.  Soc,  1911. 


Fig.  Ill  — HoESESHOE  Kidnbt. 


MALFORMATION  OF  THE  KIDNEY  535 

combined  mass.  The  commonest  form  of  fusion  is  the  horse&Iioe  hidney. 
The  two  kidneys  lie  usually  a  little  lower  than  their  normal  position 
with  their  lower  poles  bound  together  either  by  a  band  of  fibrous  tissue, 
or  by  an  isthmus  of  actual  renal  tissue.  This  isthmus  in  9  cases  out 
of  10  lies  in  front  of  the  great  vessels.  The  ureters  usually  pass  down 
in  front  of  the  isthmus.  (Fusion  of  the  upper  pole  is  extremely  rare.) 
Thirty  cases  were  found  in  21,218  autopsies  (1  in  707  collected  by 
Morris  Preinelsverger  and  Socin).^  Eovsing  ^  records  as  extreme  sta- 
tistics the  reports  of  Kraft  and  Scheel,  who  found  12  cases  in  9,142  au- 
topsies (1  in  500),  and  Eibiger,  who  found  but  1  horseshoe  kidney 
among  2,294  autopsies.  I  have  encountered  the  condition  twice  in  less 
than  200  operations  for  renal  disease.  The  ''S"  or  sigmoid  kidney  is  a 
form  of  renal  fusion  in  which  one  kidney  lies  below  the  other,  each 
organ  being  somewhat  misshapen ;  and  the  upper  pole  of  one  being 
fused  to  the  lower  pole  of  the  other.  The  remaining  rare  conditions 
may  be  classified  as  the  "misshapen  kidney."  Such  kidnej^s  are  often 
misplaced,  and  usually  in  the  middle  line  near  the  promontory  of  the 
sacrum. 

Eovsing,  as  a  result  of  an  examination  of  4  cases,  has  constructed 
a  clinical  picture  of  horseshoe  kidney  consisting  of  a  pain  across  the 
abdomen  induced  by  exertion,  exaggerated  when  the  patient  bends  over 
backward,  and  relieved  by  lying  down.  The  tumor,  he  says,  can  be  pal- 
pated in  front  of  the  great  vessels.  I  suspected  horseshoe  kidney  in 
one  of  my  cases  because  of  early  bilateral  tuberculosis.  Careful  ex- 
amination failed  to  reveal  any  of  these  symptoms,  but  operation  showed 
a  horseshoe  kidney.  The  condition  is  usually  diagnosed  during  opera- 
tion by  finding  the  ureter  in  front  of  the  lower  pole  of  the  kidney, 
and  later  identifying  the  connecting  band.  If  one  may  judge  from  two 
cases,  operations  upon  the  horseshoe  kidney  present  no  very  unusual 
difficulties.  In  the  case  mentioned  above,  half  of  the  tuberculous  horse- 
shoe kidney  was  successfully  removed. 

Supernumerary  Kidney .^The  presence  of  rudimentary  function- 
less  supernumerary  masses  of  kidney  tissue  has  been  noted  a  number 
of  times.  The  condition  has  no  surgical  interest.  The  presence  of  a 
supernumerary  functionating  kidney  in  man  is  extremely  rare. 
Kretschmer  ^  has  reviewed  the  subject  and  reported  a  case.  The 
operative  diagnosis  may  be  difficult. 

The  presence  of  three  ureters  usually  means  simply  a  bifurcation 
of  the  excretory  apparatus,  while  in  some  of  the  reported  cases  of 
supernumerary  kidney  the  ureter  from  this  has  joined  the  ureter  from 
the  other  kidney  of  the  same  side  before  entering  the  bladder.     Were 

^Keyes,  " Genito-Urinary  Diseases,"   1910,  page  584. 
"^  Hospitals  Tidende,   3910,  liii,  1481. 
^Jour.  A.  M.  A.,  ]915,  Ixv,  1447. 


536  MALFORMATIONS  OF  THE  KIDNEY  AND  UEETER 

the  condition  suspected  it  might  be  identified  by  pyelography.  The 
operative  treatment  of  surgical  conditions  occurring  in  the  super- 
numerary kidney  probably  presents  no  peculiar  difficulties. 


ABNORMALITIES  OF  THE  URETER 

Absence  of  Ureter — Absence  of  the  ureter,  of  course,  implies  the 
absence  of  the  corresponding  kidney.  Absence  of  kidney  does  not, 
however,  necessarily  imply  absence  of  the  corresponding  ureter.  A 
portion  of  this  may  persist,  and  may  even  be  patent,  though  it  is  likely 
to  be  so  narrow  as  not  to  admit  a  ureter  catheter. 

Reduplication  of  Ureter. — One  of  the  commonest  of  anomalies  of 
kidney  and  ureter  is  a  bifurcation  of  the  renal  pelvis,  each  narrow  pelvis 
leading  into  a  separate  ureter  which  extends  for  a  short  distance  before 
the  two  join.  Total  reduplication  is  said  by  Wedensky  ^  to  occur  in 
at  least  1  per  cent  of  cases,  usually  on  the  left  side.  The  double  ureter 
is  often  not  associated  with  any  notable  malformation  of  the  kidney, 
but  a  number  of  cases  have  been  reported  with  infection  in  one  of  the 
pelves,  but  not  in  the  other  (cf.  Stevens).^  The  condition  has  also 
led  to  confusion  in  diagnosis,  since  on  one  catheterization  the  urine  ap- 
pears normal,  and  on  a  subsequent  one,  perhaps  by  a  different  observer, 
the  urine  from  the  same  kidney  is  found  purulent.  Indeed  the  condition 
has  led  to  a  false  diag-nosis  of  the  spontaneous  cure  of  renal  tubercu- 
losis. 

The  ureter  from  the  lower  kidney  pole  takes  the  normal  course, 
and  enters  the  trigone  at  its  usual  angle.  The  ureter  from  the  upper 
pole  is  longer  at  both  ends,  it  enters  the  bladder  at  some  point  below 
the  angle  of  the  trigone. 

Crossed  Ureters — A  fused  kidney  on  one  side  of  the  median  line 
necessitates  the  ureter  to  that  kidney  crossing  the  median  line  in  order 
to  get  to  its  proper  place  in  the  bladder.  Braasch  has  a  unique  illustra- 
tion of  a  ureter  crossing  the  median  line  to  join  the  opposite  ureter 
and  then  enter  by  one  orifice  into  the  bladder. 

Abnormalities  of  Implantation.^Abnormal  implantation  of  the 
ureter  into  the  pelvis  results  in  hydronephrosis  (page  457).  Abnormal 
implantation  of  the  ureter  in  the  bladder  is  usually  associated  with  a 
supernumerary  ureter.  Hartman  ^  has  reported  37  cases  of  extra- 
vesical  opening  of  the  ureter,  14  of  them  were  supernumerary.  The 
orifice  was  in  Gaertner's  duct  (2)  ;  the  vestibule  (21)  ;  the  vagina  (8)  ; 
the  urethra  (0).  Wedensky  reports  2  cases  of  termination  of  the  ureter 
in  the  prostatic  urethra. 

•    ^  Folia  Urol,  Oct.,  1911,  page  345. 

'Jour.  A.  M.  A.,  1912,  lix,  2298. 

^Zeitschr.  f.  GynciTc.  Urol,  1913,  iv,  69. 


ABNORMALITIES  OF  THE  URETER  537 

Mucli  more  frequently  the  supemumerarj  ureter  terminates  in  some 
part  of  the  trigone  between  its  angle  and  the  urethral  orifice.  If  near 
the  urethra,  the  abnormally  situated  ureteral  mouth  may  lead  to  in- 
continence of  urine.  In  this  event  the  ureter  may  be  reimplanted  in  the 
vault  of  the  bladder  or  it  may  be  resected  with  the  portion  of  the 
kidney  that  empties  into  its  pelvis. 

Stricture  of  the  Ureter. — Congenital  stricture  has  been  studied  by 
Bottomley.^  Strictures,  valves  and  partial  atresia  have  been  noted  in 
various  portions  of  the  ureter.  They  are  commonest  at  the  bladder 
orifice  where  they  lead  to  the  intravesical  ureteral  cyst  (see  below) 
and  at  a  point  at,  or  near,  the  entrance  of  the  ureter  into  the  bladder 
wall.  With  congenital  stricture  is  usually  associated  a  congenital 
dilatation  of  the  ureter  and  kidney  pelvis  above.  The  stricture  may  be 
so  slight  that  it  causes  no  symptoms  until  adult  life  is  reached,  but  the 
usual  result  is  congenital  hydronephrosis. 

Intravesical  Ureteral  Cyst — Stricture  of  the  ureter,  at  its  point  of 
entrance  into  the  bladder  cavity,  is  not  so  very  uncommon.  The  orifice 
may  be  reduced  to  so  small  a  size  that  it  would  scarcely,  or  not  at  all, 
admit  a  ureter  catheter.  As  a  result  the  ureter  above  dilates,  and  espe- 
cially that  portion  of  it  which  lies  underneath  the  mucous  membrane 
of  the  bladder.  This  dilatation  produces  the  so-called  intravesical 
ureteral  cyst.  It  may  reach  an  enormous  size,  and  may  even  be  pro- 
truded from  the  urethra  in  the  female.  The  smaller  cysts  are  quite 
common  and  are  associated  with  intermittent  hydronephrosis  as  a  rule. 
The  obstruction  is  readily  relieved  by  biting  with  the  cystoscopic  forceps 
or  scissors  a  sufficiently  large  hole  in  the  overlying  mucous  membrane 
of  the  bladder. 

^Annals  of  Surgery,  November,  1910. 


CHAPTER    LVI 

MALFORMATIONS  OF  THE  BLADDER  AND  URETHRA 

MALFORMATIONS  OF  THE  BLADDER 

EXSTROPHY 

Exstrophy  or  extroversion  of  the  bladder  (ectopia  vesicae)  is  far 
more  common  in  the  male  than  in  the  female.  Thus,  of  the  49  cases  col- 
lected by  Pousson/  37  were  men  and  12  women.  I*ieudoerfer  estimates 
one  case  to  50,000  births  and  eight  boys  to  one  girl.  Smeed  reports 
3  cases  to  28,000  births  (Edmunds^).  In  the  female  it  does  not  pre- 
vent copulation.  Cases  of  pregnancy  and  successful  delivery  at  term 
are  recorded. 

The  deformity  is  an  arrest  of  development  in  the  median  line  anal- 
ogous to  harelip,  and  is  found  in  different  degrees.  In  a  typical  case 
the  lower  abdominal  wall  and  the  front  wall  of  the  bladder  are  absent. 
The  pubic  bones  are  separated,  their  ends  being  united  by  a  strong 
band  of  fibrous  tissue.  The  posterior  wall  of  the  bladder,  pressed  out 
by  the  intestines,  forms  a  mottled,  red,  tomatolike  tumor,  occupying 
the  position  of  the  symphysis  pubis.  Inguinal  hernia  of  one  or  both 
sides  is  commonly  present.  The  scrotum  is  usually  normal,  containing 
the  testicles.  The  penis  is  rudimentary,  and  affected  by  complete 
epispadias.  The  ureters  are  sometimes  greatly  dilated,  forming,  as  it 
were,  rudimentary  bladders.  The  pathology  and  etiology  are  given  in 
detail  by  Connell  ^  and  Hovelacque.* 

In  exstrophy  of  the  bladder  the  patient's  condition  is  miserable  in- 
deed. The  mucous  membrane  covering  the  protruded  posterior  wall  of 
the  everted  bladder  is  inflamed,  thickened,  ulcerated,  and  covered  by 
decomposing  stringy  mucous,  the  whole  bathed  in  ammoniacal  urine. 

The  integument  of  the  abdomen  and  thighs  becomes  excoriated  and 
inflamed.  The  friction  of  garments  in  walking  only  serves  to  aggravate 
the  existing  difficulties,  and  the  sufferer  is  in  a  truly  pitiable  condition. 

Vulliet  ^  states  that  41  per  cent  of  the  little  sufferers  die  within 

^Gv.ym's  Annales,  1888,  vi,  94,  155,  244,  337,  409,  471,  536,  615. 
Tractit.,  1914,  xcii,  501. 
^Jour.  Am.  Med.  Assn.,  1901,  xxxvi,  637. 
*Jour.  d'Vrol.,  1912,  i,  No.  2. 
^     *Lyon  Clm.,  1913,  ix,  589. 

538 


MALFORMATIONS  OF  THE  BLADDER 


539 


Fig.  112. 


5  years;  18  per  cent  in  the  next  5  years,  and  almost  all  the  survivors 

perish  before  the  age  of  15.     Death  is  usually  due  to  renal  infection. 
Treatment. — Palliative     Treatment. 

— This  consists  in  wearing  an  appropriate 

urinal.     ISTo  urinal  can  be  well  arranged  for 

an  infant  or  a  young  child,  and  at  this  time 

vaselin  and  hot  water  are  our  only  arms 

against  the  disease.    In  later  life  a  metallic 

shield,    preferably    of    silver,    sufficiently 

bulged  to  contain  the  protruding  vesical  wall 

without  coming  into  contact  with  it  may  be 

worn.    From  the  lower  part,  which  is  slight- 
ly bellied  downward,  extends  a  tube  upon 

which  is  fitted  a  long,  flat  rubber  bag,  to  be 

worn  strapped  to  the  thigh,  and  to  serv^e  as 

a  reservoir  for  the  urine  (Fig.  112).     The 

instrument  may  be  kept  clean  by  a  weak 

solution  of  formalin. 

Operative      Treatment.  —  Palliative 

treatment     is     inefficient,     but     operation 

should  be  postponed  until  the  child  is  from  six  to  eight  years  of  age. 
Of  the  many  plastic  operations  that  have  been  suggested,  none  re- 
constructs  a  bladder  ex- 
cepting Trendelenburg's.-^ 
The  aim  of  this  operation 
■rw^        \,i^     '-'.       '^^HBHB  .»^  i^  ^^  obliterate  the  cleft 

^^f^'  _      ^^m^  ''^^M  ill  the  bladder  and  belly 

wall  by  bringing  the  pu- 
bic bones  together.  This 
is  accomplished,  first  of 
all,  by  wearing  a  belt, 
subsequently  by  division 
of  the  sacro-iliac  synchon- 
droses. With  the  bones 
thus  reunited,  the  blad- 
der retracts  into  the  pel- 
vis, and  the  suprapubic 
fistula  may  be  closed. 
The  treatment  requires 
several  years.  It  is  very 
difficult  to  reconstruct 
the  sphincter. 
TliG  transplantation  operations  achieve  somewhat  better  results ;  but 
^  Berlin.  Jclin.  Wochenschr.,  1915,  lii,  9. 


FlQ 


113. — Sacculated   Bladder 
retention. 


Due    to    prostatic 


540        MALFORMATIONS  OF  THE  BLADDER  AND  URETHRA 

require  great  technical  skill.  Peter's  is  the  easiest  to  perform ;  Maydl's 
sometimes  succeeds.  Coffey  and  Mayo  have  had  great  success  with 
the  technic  devised  by  the  former  on  condition  that  each  ureter  be 


FiQ.  114. — Cystography  Showing   Diverticulum.     "Visible  catheter  in  opposite  ureter. 

transplanted  separately.     Cutaneous  transplantation  is  not  to  be  con- 
sidered for  children. 

DIVERTICULUM 

Probably  most  bladder  diverticula  are  congenital.  The  so-called 
double  bladder  is  a  form  of  diverticulum.  Multiple  small  diverticula 
evidently  result  from  the  back  pressure  of  stricture  and  prostatism 
(Fig,  11'^),  bul.  the  typical  large  diverticulum  usually  shows  symptoms 
before  the  age  of  prostatism  and  often  in  a  patient  who  has  no  history 
of  venereal  disease  or  evidence  of  stricture  (Fig,  114).     Fischer^  con- 

1  Surg.,  Gyn.  tt  Ohstet.,  February,  1910,  page  156.  See  also  Sherill,  Am.  Jovr, 
Urol,  191.5,  xi,  303. 


MALFORMATIONS  OF  THE  BLADDER  541 

cedes  their  congenital  origin,  but  rejects  the  theory  of  Englisch,  that  the 
diverticuhim  is  due  to  some  obstruction  in  the  urinary  outflow  which 
has  subsequently  disappeared.  He  believes  with  Badenstecher  that  the 
diverticulum  is  "produced  by  a  folding  in  of  the  bladder  wall  brought 
about  by  a  superfluity  of  embryonal  tissue  which  has  to  accommodate 
itself  to  a  certain  space  in  the  pelvis." 

Pathology. — ''The  word  diverticulum  should,  I  think,  be  con- 
fined to  those  cases  of  pouches  always  of  congenital  origin  occurring 
most  frequently  in  certain  positions  but  ocasionally  seen  in  almost  any 
portion  of  the  bladder,  and  not  due  to  defective  development  or  lack  of 
closure  of  any  recognized  structure"  (such  as  the  urachus)  ( Cabot). ^ 
The  walls  of  diverticula  are  made  up  of  the  normal  coats  of  the  bladder, 
but  their  musculature  is  weak,  and  becomes  rapidly  destroyed  by 
inflammation. 

The  usual  situation  for  the  orifice  is  not  far  behind  or  lateral  to  the 
orifice  of  the  ureter.  Indeed,  the  ureteral  orifice  may  open  within  the 
diverticulum.  Hydro-  and  pyonephrosis  result  from  kinking  of  the 
ureter  about  a  diverticulum ;  or  from  distortion  of  the  orifice  of  the 
ureter,  when  this  opens  within  the  sac. 

As  a  result  of  inflammation,  stone  may  form  in  a  diverticulum; 
tumors  may  also  grow  therein. 

Symptoms — The  uninflamed  diverticulum  is  practically  symptom- 
less. Therefore  a  patient  may  reach  a  considerable  age  before  this 
congenital  lesion  gives  any  symptoms,  though  if  the  patient  be  intelli- 
gent, and  the  diverticulum  large,  close  questioning  will  usually  reveal 
the  fact  that  there  has  been  some  unusual  quality  in  urination,  either 
an  ability  to  hold  an  unusually  large  quantity  of  urine,  or  a  difficulty  of 
urination,  extending  back  for  many  years. 

The  onset  of  symptoms  (usually  the  age  at  which  infection  began) 
is  shown  in  the  following  table  made  up  of  the  cases  collected  by 
Fischer,  Cabot  and  Lower. ^ 

Below  20  years  of  age 3  cases 

20  to  30    6  cases 

30  to  40    10  cases 

40  to  50    11  cases 

50  to  60    8  cases 

60  to  70    8  cases 

TO  to  80    3  cases 

There  were  59  men  and  5  women. 

The  clinical  picture  is  a  combination  of  infection  and  retention. 
Among  the  younger  patients,  as  a  rule,  the  history  is  that  a  chronic 
^Boston  Med.  #  Surg.  Jour.,  1915,  clxxii,  300,  365. 
'Jour.  A.  M.  A.,  1914,  Ixiii,  2015. 


542    MALFORMATIONS  OF  THE  BLADDER  AND  URETHRA 

gonorrhea  does  not  get  well,  or  that  they  have  difficnlty  in  emptying 
the  bladder,  and  a  catheter  reveals  a  certain  amount  of  residual  urine. 
The  older  the  patient,  the  more  the  symptoms  of  retention  predominate, 
and  hematuria  may  be  added  if  there  is  stone  or  tumor.  If  the  disease 
begins  early  m  life  the  symptoms  may  be  mild  for  many  years.     In 


Fig.  115. — Cystography  Showing  Large  Phlebolith  Near  Bladder.     This  might  be 

mistaken  for  a  diverticulum. 

several  of  my  patients  the  symptoms  went  back  for  more  than  ten  years 
before  cystoscopy  revealed  the  true  condition. 

Diagnosis. — One  may  suspect  the  presence  of  a  diverticulum  when- 
ever there  is  a  prolonged  chronic  infection  of  the  urethra  or  bladder  with 
even  a  small  amount  of  residual  urine,  or  whenever  there  is  residual 
urine  otherwise  unaccounted  for.  The  diagnosis  may  usually  be  made 
by  cystoscopy  which  reveals  the  orifice  of  the  diverticulum.  A  ureter 
catheter  passed  into  the  diverticulum  shows  whether  this  is  large 
enough  to  be-worthy  of  comment  or  not.  Before  operating,  the  diagnosis 
is  still  further  confirmed  by  cystophotography  with  the  bladder  filled 


PLATE    XVIII 


Fig.  1 


Fig. 


Stereoscopic  Cystograms  of  Diverticula. 

Fig.  1. — Taken  from  the  left,  the  small  diverticulum  stands  out. 
Fig.  2. — Taken  from  the  right,  the  large  diverticulum  stands  out. 


MALFORMATIONS  OF  THE  URETHRA  543 

with  5  per  cent  collargol  or  some  other  visible  fluid  (Figs.  114,  115). 
Since  the  pouches  usually  protrude  to  either  side  of  the  bladder  radio- 
graphs should  be  taken  at  an  angle  similar  to  that  usually  employed 
in  taking  stereoscopic  radiograms  (PI.  XVIII). 

Treatment. — The  treatment  is  entirely  operative  (page  723).  A 
diverticulum  behind  a  large  prostate  should  not  be  operated  upon  until 
after  prostatectomy.  Indeed,  in  most  instances  the  prostatectomy  suf- 
ficiently alleviates  the  symptoms. 

URACHUS  CYST,  OR  FISTULA 

Toward  the  middle  months  of  intra-uterine  life  the  urachus  (the 
canal  connecting  the  bladder  with  the  umbilicus)  becomes  obliterated. 
Exceptionally,  it  remains  patent  throughout  or  at  one  extremity.  This 
patency  gives  rise  to  a  urachus  cyst,^  or  fistula,^  as  the  case  may  be. 
Urachus  cyst  is  exceedingly  rare.  I  have  seen  one  in  an  adult  which 
formed  a  large,  irregular,  fluctuating,  hypogastric  tumor. 

Urachus  fistula  is  commonly  a  congenital  condition,  and  is  usually 
caused  by  urethral  obstruction.  The  urachus  may  open  in  adult  life  as 
a  result  of  urethral  obstruction,  but  doubtless  this  does  not  occur  unless 
there  has  been  some  congenital  defect  in  the  closure  of  the  canal. 
Urachus  fistula  may  be  distinguished  from  fistulae  resulting  from  the 
bursting  of  an  abscess  or  from  malignant  infiltration. 

The  treatment  of  urachus  cyst,  or  fistula,  consists  in  the  excision  of 
the  canal  or  cyst  after  the  urethral  obstruction  has  been  removed.  In- 
deed, some  fistulae  have  been  closed  by  merely  removing  the  obstruc- 
tion and  curetting  the  canal. 


MALFORMATIONS  OF  THE  URETHRA 

The  urethra  is  subject  to  arrest  and  error  of  development,  but  is  not 
often  seriously  deformed.  Among  curiosities  of  deformity  may  be 
mentioned  abnormal  position  of  the  meatus  on  the  side  of  the  glans 
penis;  termination  of  the  ejaculatory  ducts  in  a  separate  canal,  running 
along  the  dorsum  of  the  penis  and  opening  behind  the  glans  (gonorrhea 
of  this  canal  has  been  noted)  ;  and  termination  of  the  urethra  in  the 
groin.  Le  Fort  ^  has  collected  and  classified  the  difl^erent  varieties  of 
fistula  of  the  penis  and  the  so-called  double  urethra,  and  shows  that  the 
second  urethra  is  always  a  blind  pouch,  usually  a  prolongation  of  the 

^Weiser,  Annals  of  Surg.,  October,  1906. 
^  Binnie,  Jour.  Am.  Med.  Assn.,  1906,  xlvii,  109. 

^Guyon's  Annates,  1896,  xiv,  624,  792,  912  and  1095.  See  also  MacKenzie, 
Burg.,  Gynec.  and  Obstet.,  1916,  xxii,  344. 


544   MALFORMATIONS  OF  THE  BLADDER  AND  URETHRA 

lacuna  magna.     In  fact,  double  urethra  does  not  exist,  except  with 
double  penis. 

These  deformities,  dependent  upon  excessive  and  unnatural  de- 
velopment, are  exceedingly  rare.  Deformities  caused  by  a  defect  of 
development  are  more  common.  Either  the  canal  is  obstructed  or  it  is 
not  closed  in.  In  the  former  case  the  junctions  among  the  various  parts 
of  which  the  canal  is  formed  are  incomplete  (atresia — congenital  stric- 
ture) ;  in  the  latter  the  closure  of  the  walls  is  defective  (hypospadias — 
epispadias). 

ATRESIA 

Atresia,  commonest  at  the  meatus,  may  occur  at  any  part  of  the 
canal.    Indeed,  the  entire  urethra  may  be  replaced  by  a  fibrous  cord. 

The  obstruction  is  usually  but  a  thin  membrane  which  may  be  punc- 
tured and  the  orifice  kept  patent  until  it  heals,  after  which  no  further 
trouble  need  be  anticipated.  If,  however,  the  urethra  is  imperforate 
for  some  distance,  it  may  be  punctured  with  a  small  trocar,  but  only 
after  the  internal  segment  has  been  accurately  located  by  external  ure- 
throtomy, or,  if  the  membranous  urethra  is  also  involved,  by  suprapubic 
cystotomy.  In  these  cases  the  urachus  often  remains  patent,  and  the 
patient  urinates  through  this.  Eemoval  of  the  urethral  obstruction  is 
soon  followed  by  closure  of  the  urachus.  Englisch  ^  has  furnished  a 
contribution  to  this  subject.  The  stricture  liable  to  ensue  upon  punc- 
ture of  the  diaphragm  or  of  a  band  must  be  combated  by  the  usual 
methods.  Major  surgical  procedures  are  best  delayed,  if  possible,  until 
the  patient  has  attained  his  sixth  or  eighth  year. 


CONGENITAL  STRICTURE 

Congenital  stricture,  usually  of  the  meatus,  is  so  common,  and 
has  such  a  direct  bearing  upon  the  treatment  of  the  so-called  organic 
stricture,  that  it  is  considered  in  that  connection. 

I  have  seen  several  congenital  strictures  elsewhere  in  the  canal, 
usually  in  its  scrotal  portion.  These  are  usually  mistaken  for  gonor- 
rheal strictures.  But  careful  dissection  reveals  a  congenital  over- 
riding of  the  two  ends  of  the  canal  which  is  pathognomonic  of  con- 
genital stricture. 

DILATATION  OF  THE  URETHRA 

Bokay  ^  has  collected  14  cases  of  congenital  urethral  diverticula, 
only  3  of  which  were  due  to  stricture. 

^Arsh.  f.  Kinderheilk.,  1881,  ii,  85  and  291. 
'^Dermatolog.  Zeitschr.,  1900,  vii,  721. 


MALFORMATIONS  OF  THE  URETHRA  545 

PROLAPSE  OF  URETHRA  IN  LITTLE  GIRLS 

"Briining  ^  reports  a  case  of  the  sudden  prolapse  of  the  entire  mucous 
lining  of  the  urethra,  without  apparent  cause,  in  a  healthy  girl  of  8. 
Study  of  the  literature  on  this  subject  shows  that  this  occurrence  is 
observed  in  girls  only  in  early  infancy  and  between  the  ages  of  8  and  12. 
Hemorrhage  accompanied  the  prolapse  in  41  per  cent  of  the  seventy-six 
cases  he  has  found  and  tabulated.  In  a  large  proportion  of  the  cases  the 
prolapse  was  not  recognized  and  dire  results  followed  the  treatment 
based  on  a  mistaken  diagnosis.  The  child  should  be  kept  in  bed  and 
astringent  and  cauterizing  measures  should  be  applied  after  reduction. 
If  these  fail  or  if  the  prolapse  is  total,  he  advises  resection  of  the  sag- 
ging portion  and  suture.  The  operative  loss  oi  blood  has  always  been 
slight." 

HYPOSPADIAS 

Hypospadias  is  that  forai  of  imperfect  development  of  the  urethra 
in  which  the  canal  terminates  in  an  opening  in  its  lower  wall  instead  of 
extending  to  its  normal  termination  in  the  end  of  the  glans  penis.  There 
are  three  degrees  of  hypospadias:  (1)  balanitic  hypospadias,  in  which 
the  urethra  opens  on  the  lower  surface  of  the  glans  or  at  the  peno- 
balanitic  junction;  (2)  penile  hypospadias  (penoscrotal  and  scrotal 
hypospadias),  in  which  the  canal  opens  on  the  under  surface  of  the 
penile  urethra,  usually  at  the  penoscrotal  angle;  and  (3)  per  meal  hy- 
pospadias, in  which  the  urethra  terminates  in  front  of  the  triangular 
ligament  and  opens  in  the  perineum.  Thus  hypospadias  always  occurs 
in  front  of  the  cut-off  muscle,  and,  no  matter  how  extensive  it  may  be, 
the  patient  has  control  over  the  escape  of  urine.  Hypospadias  at  the 
penoscrotal  angle  is  more  common  than  the  perineal  variety,  and  most 
frequent  of  all  is  balanitic  hypospadias.  That  part  of  the  urethra  lying 
between  a  hypospadial  opening  and  the  meatus  is  usually  absent. 

Hypospadias,  as  commonly  encountered  in  practice,  consists  in  an 
absence  of  the  frenum  preputii  and  a  flaring  open  of  the  meatus  in- 
f eriorly,  or  an  opening  in  the  floor  of  the  canal  within  a  few  lines  of  the 
natural  meatus,  the  position  of  which  latter  is  usually  marked  more  or 
less  perfectly  in  its  iTsual  site.  The  hypospadic  urethral  orifice  is 
always  contracted.  With  penile  hypospadias  there  is  usually  some 
downward  curvature  of  the  penis,  and  not  infrequently  adliesion  of  the 
penis  to  the  scrotum:  the  condition  may  be  called  one  of  permanent 
physiological  chordee.  The  penis,  freed  of  all  cutaneous  and  urethral 
attachments,  cannot  be  straightened  until  the  fibrous  sheaths  of  both 
corpora  have  been  transversely  incised  beneath,  and  sometimes  not  until 
the  fibrous  septum  has  been  incised. 

^Jahrb.  f.  Kinderh.,  1911,  Ixxiv,  1  (by  Jour.  A.  M.  A.), 


546    MALFORMATIONS  OF  THE  BLADDER  AND  URETHRA 

With  perineal  hypospadias  the  scrotum  is  bifid,  and  the  penis  is 
usually  very  imperfectly  developed,  imperforate,  and  looks  like  a 
large  clitoris.  The  bifid  scrotum  passes  very  well  for  a  vulva.  This  is 
a  common  type  of  pseudohermaphrodite. 

Etiology. — Hypospadias  is  a  simple  arrest  of  development  in  a 
portion  of  the  lower  wall  of  the  urethra,  its  lateral  halves  failing  tc 
unite  in  the  median  line.  In  favor  of  this  view  are  the  manifest 
hereditary  tendency  to  this  deformity  seen  in  some  cases,  and  the  fact 
that  at  two  months  the  embryo  has  hypospadias  normally.  The  scrotum 
has  not  yet  united,  and  if  natural  development  ceases  here  the  last 
degree  of  hypospadias  results.  It  may  be  urged  that  this  theory  does 
not  explain  the  incurvation  of  the  penis,  nor  its  adhesion  to  the  scrotum, 
nor  the  scarlike  contracted  appearance  of  the  orifice.  To  explain  these 
facts  Kaufmann  ^  advanced  the  theory  that  hypospadias  and  epispadias 
are  examples  of  congenital  fistula  dependent  upon  imperfect  union  of 
the  penile  and  the  balanitic  urethra.  These  two  portions  of  the  canal,  it 
is  known,  are  developed  separately,  and  if  imperfectly  approximated 
atresia  at  the  penobalanitic  junction  may  result.  ISTow,  Kaufmann  sup- 
poses that  the  urine  secreted  by  the  fetus  may  break  either  through 
the  obstruction,  leaving  congenital  fistula,  or  through  the  floor  of  the 
canal,  producing  hypospadias,  or  through  its  roof,  thus  causing  epi- 
spadias. This  theory  explains  incurvation  and  adhesion  but  not  mal- 
position of  the  urethra  in  epispadias,  or  exstrophy  of  the  bladder,  with 
aonunion  of  the  symphysis  pubis — phenomena  so  closely  related  to  epi- 
spadias that  no  theory  which  does  not  elucidate  them  can  be  invoked  to 
account  for  the  urethral  deformity. 

Symptoms. — Balanitic  hypospadias  is  unimportant;  many  patients 
have  it  without  being  aware  of  the  fact,  while  the  greatest  inconvenience 
it  produces  is  a  slight  imperfection  in  erection  and  a  dribbling  at  the 
end  of  urination.  With  penile  or  perineal  hypospadias,  however,  the 
patient  may  be  forced  to  urinate  in  a  squatting  posture  to  keep  from 
wetting  himself,  erection  may  be  very  imperfect,  and  there  may  be  im- 
potence from  inability  to  throw  the  semen  into  the  vagina. 

An  associated  inconvenience  is  the  necessity  of  enlarging  the  con- 
tracted meatus,  in  order  to  introduce  dilating  instruments,  in  case  of 
stricture. 

Treatment. — Eor  balanitic  hypospadias  no  treatment  is  actually 
necessary  unless  a  meatotomy  to  permit  the  introduction  of  instruments 
into  the  urethra. 

But  if  the  patient  demands  radical  operation.  Beck's  procedure 
should  be  employed. 

For  penile  and  perineal  hypospadias  operation  is  always  required 
(p.  Y68). 

*" Deutsche  Chirur^ie,"  1886,  1    (a),  60. 


MALFORMATIONS  OF  THE  URETHRA  547 

EPISPADIAS 

Epispadias  is  a  fissure  of  the  superior  wall  of  the  urethra  with 
ectopia  of  the  canal  (Guy on).  It  is  extremely  rare.  According  to 
Baron/  epispadias  occurs  once  for  150  cases  of  hypospadias,  but  Mar- 
shall did  not  find  a  single  case  of  epispadias  in  examining  60,000 
conscripts.-  The  epispadias  may  be  balanitic  or  penile,  or  the  urethra 
may  be  entirely  laid  open.  This  complete  epispadias  is  almost  always 
accompanied  by  exstrophy  of  the  bladder.  The  epispadic  orifice  is 
large,  and  sometimes  the  finger  may  even  be  passed  through  it  into  the 
bladder.  The  prepuce  forms  a  knob  of  loose  tissue  below  the  glans. 
The  penis  is  short  and  thick,  or  small  and  more  or  less  deviated.  It  is 
usually  adherent  to  the  scrotum,  sometimes  practically  buried  in  it. 
The  pubic  bones  may  be  separated  even  when  there  is  no  exstrophy  of 
the  bladder,  and  there  may  be  hernia  of  that  organ  without  exstrophy. 

Etiology — The  observations  made  upon  the  etiology  of  hypospadias 
apply  equally  well  to  this  condition.  Epispadias  is  certainly  an  arrest 
of  development  in  the  upper  wall  of  the  urethra,  but  it  is  still  a  matter 
of  hypothesis  how  the  urethra  gets  above  the  united  corpora  cavernosa ; 
for  even  when  the  genital  buds  which  are  to  form  the  corpora  cavernosa 
are  still  separate  at  the  fortieth  day  of  fetal  life,  the  urethra  is  beneath 
them.  With  exstrophy  of  the  bladder,  where  the  lower  portion  of  the 
abdominal  wall  is  lacking  and  the  pubic  bones  do  not  come  together,  it 
is  easier  to  understand  how  the  roof  of  the  urethra  may  bft  wanting 
throughout. 

Symptoms — The  symptoms  consist  in  the  functional  derangement 
of  micturition,  erection,  and  emission,  as  in  hypospadias ;  but  it  is  to  be 
noted  that  incontinence  of  urine,  which  never  complicates  hypospadias, 
is  usually  the  main  feature  of  severe  cases  of  epispadias,  and  this  cries 
out  for  operation  m(ye  loudly  and  incessantly  than  even  the  most 
aggravated  symptoms  of  hypospadias.  Unfortunately,  it  is  precisely 
here  where  operations  are  most  in  demand  that  they  accomplish  least. 

Treatment — For  the  milder  cases,  uncomplicated  by  the  loss  of 
sphincter  power,  the  counsel  to  bear  their  woes  patiently  is  a  good  one. 
The  methods  hitherto  employed  to  relieve  this  condition — even  the  fa- 
vored procedures  of  Thiersch  and  Duplay — are  tedious  and  fraught 
with  faihires.  In  view,  however,  of  the  success  of  the  ISTove-Josserand 
operation  for  hypospadias,  I  should  be  tempted  to  try  it  for  simple 
penile  epispadias.  In  addition  to  the  changes  obviously  necessary  to 
adapt  the  operation  to  epispadias  it  would  be  necessary  to  divert  the 

^Dolbeau,  op.  cit.,  p.  11. 

^Englisch  {Bull,  med.,  Paris,  1895,  ix,  153)  has  reported  a  ease  of  eompleto 
separation  of  the  penis  into  lateral  halves,  each  corpus  cavernosum  forming  a  i^enis 
by  itself,  and  the  urethra  opening  between  tliem. 


548    MALFORMATIONS  OF  THE  BLADDER  AND  URETHRA 

stream  of  urine,  and  it  might  seem  advisable  to  connect  the  new  and 
the  old  urethra  by  continuing  the  graft  into  the  outer  extremity  of  the 
epispadic  urethra  previously  denuded. 

When  the  sphincter  is  lost  it  cannot  be  replaced. 

The  complicating  adhesions,  torsion  or  flexion  of  the  penis,  must  be 
dealt  with  here,  as  in  hypospadias,  by  liberating  incisions  of  the  skin 
and  the  sheaths  of  the  cavernous  bodies. 


CHAPTER    LYII 
DISEASES  OF  THE  SCROTUM 

ANATOMY 

The  scrotum  is  a  pouch  foiTiied  of  skin  and  of  muscular  and  con- 
nective tissue.  Its  function  is  to  contain  and  support  the  testicles.  It 
is  developed  from  lateral  halves  which  unite  centrally  in  the  raphe, 
a  raised  line  continuous  with  the  raphe  of  the  penis  and  that  of  the 
perineum.  The  integument  of  the  scrotum  is  delicate  in  structure, 
covered  with  a  few  hairs,  and  likely  to  become  pigmented  at  puberty. 
The  sebaceous  glands  are  very  large. 

The  dartos  is  a  layer  of  unstriped  muscle  firmly  attached  to  the 
integument,  and  reflected  inward  from  the  raphe,  to  form  the  septum 
scroti.  On  exposing  the  scrotum  to  the  air,  the  vermicular  contractions 
of  this  muscle  can  be  readily  seen.  They  occur  under  the  influence 
of  cold  or  fright,  and  during  the  venereal  orgasm.  In  youth,  especially 
in  winter,  the  dartos  is  habitually  contracted  and  holds  the  testicles 
well  up  under  the  pubes.  The  ancient  sculptors  did  not  fail  to  notice 
that  contraction  of  the  scrotum  was  a  mark  of  general  as  well  as  of 
sexual  vigor.  In  the  aged  and  infirm,  however,  especially  during  the 
summer,  the  muscle  relaxes,   allowing  the  testicles  to  hang  low. 

The  septum  scroti  is  pervious  to  fluids,  so  that  serum  or  infiltrated 
urine  can  find  its  way  readily  from  one  side  to  the  other.  The  lym- 
phatics of  the  scrotum  are  large  and  numerous  and  lead  to  the  inguinal 
glands. 

The  connective  tissue  within  the  scrotum,  like  that  of  the  penis,  is 
practically  devoid  of  fat.  The  muscular  dartos,  described  above,  is  the 
only  layer  of  importance.  The  space  between  it  and  the  testicle  is 
filled  with. a  loose  mesh  of  fascia  within  which  run  the  scattered  fibers 
of  the  cremaster  muscle,  and  beneath  which  the  infundibuliform  fascia, 
derived  from  the  transversalis  fascia,  forms  the  investment  of  the 
spermatic  cord. 

ANOMALIES 

The  scrotum  develops  independently  of  the  testicles,  but  if  the  latter 
fail  to  descend  it  remains  rudimentary. 

549 


550  DISEASES  OF  THE  SCROTUM 

Failure  of  union  between  the  lateral  halves  of  the  scrotum  consti- 
tutes one  of  the  features  of  pseudohermaphroditism. 


CUTANEOUS  DISEASES 

The  scrotum  may  be  affected  by  most  of  the  diseases  of  the  skin. 
Only  those  that  are  modified  by  their  position  deserve  notice. 

Eczema. — Eczema  attacking  the  scrotum  and  the  surrounding  parts 
is  sometimes  excessively  obstinate  and  prone  to  relapse. 

Acute  eczema,  urticaria  and  dermatitis  venenosa  result  in  an  enor- 
mous edematous  swelling. 

Intertrigo — Intertrigo  occurs  in  children  and  in  fat  men  of  rheu- 
matic habit.  Much  can  be  done  to  prevent  it  by  scrupulous  cleanliness, 
and  the  use  of  a  suspensory  bandage  to  keep  the  cutaneous  surfaces 
apart.  To  overcome  the  h^'peremia,  rest,  cleanliness,  and  exposure  of 
the  parts  to  the  air  are  speedily  effective  in  mild  cases.  If  the  surface 
is  moist  and  excoriated,  it  should  be  dusted  with  equal  parts  of  finely 
powdered  oxid  of  zinc,  camphor,  and  starch,  or  it  may  be  dressed  with 
the  oxid  of  zinc  ointment  or  with  a  solution  of  sulphate  of  zinc.  A 
strip  of  old  thin  linen  should  be  used  to  sling  up  the  scrotum  and  keep 
the  cutaneous  surfaces  apart.  Later,  when  the  parts  are  dry,  compound 
tincture  of  iodin,  at  first  considerably  diluted  with  water,  locally,  will 
hasten  the  cure. 

Pityriasis — In  men  with  a  delicate  skin,  especially  in  summer, 
there  is  often  a  slightly  brown  discoloration  of  the  thigh  and  the  scro- 
tum, where  the  two  surfaces  lie  habitually  in  contact,  caused  by  a 
vegetable  parasite  in  the  upper  layers  of  the  epidermis.  It  sometimes 
gives  rise  to  a  mild  local  erythema  and  considerable  itching.  A  few 
applications  of  the  compound  tincture  of  iodin  diluted  to  half  strength, 
and  painted  on  after  the  "affected  skin  has  been  washed  with  soap  and 
dried  (to  remove  the  fat  from  the  scales  and  spores),  will  cure  the  dis- 
coloration and  the  itching.    Sulphurous  acid  does  welL 

Eczema  Marginatum — This  is  another  parasitic  disease,  affecting 
the  scrotum,  thighs,  mons  veneris,  and  buttocks.  It  is  not  an  eczema, 
but  a  herpes  tonsurans  vesiculosus — a  combination  of  herpes  tonsurans 
and  intertrigo,  as  proved  by  Pick.^  The  eruption  commences  in  one 
or  more  small,  round  patches,  red,  elevated,  and  itchy,  just  where  the 
scrotum  habitually  lies  in  contact  with  the  thigh.  It  spreads  circum- 
ferentially,  healing  in  the  center.  The  border  of  the  eruption  is  sharply 
defined,  and  forms  the  distinctive  feature  of  the  disease.  It  is  com- 
posed of  papules,  vesicles,  excoriations,  and  crusts.  The  parts  within 
this  festooned  border  over  which  the  disease  has  passed  are  left  of  a 

^  Archiv  f.  Derm,  und  Syph.,  1,  iii,  443. 


INJURIES  OF  THE  SCROTUM  551 

brown  color.  Often,  little  heaps  of  dried-up  scales  lie  here  and  there 
upon  this  surface.  Patches  of  eruption  break  out  in  the  neighborhood 
or  within  the  border,  and  behave  exactly  like  the  patches  first  consti- 
tuting the  disease.  The  affection  is  slow  in  getting  well  and  tends  to 
relapse.  Friction  and  moisture  of  the  parts,  together  with  the  parasite, 
are  necessary  for  its  production.  Among  the  scales  scraped  from  the 
margin,  the  microscope  may  detect  the  moniliform  filaments  and  spores 
of  the  tricophyton  of  Malmster.  In  certain  stages  of  the  disease  the 
parasite  is  difficult  to  find. 

Treatment.  — Dilute  lead-water  or  oxid  of  zinc  ointment  may  be  used 
locally  at  first  if  there  be  much  inflammation  of  the  skin,  to  be  followed 
by  parasiticide  lotions,  or  the  latter  may  be 
commenced  with  at  once.  The  best  of  these 
is  a  mild  solution  of  corrosive  sublimate 
(1 :  10,000),  which  should  be  kept  constant- 
ly applied.  Sulphurous  acid,  pure,  is  an  ex- 
cellent parasiticide;  or  compound  resorcin 
ointment  (IST.  F.).  Treatment  should  be 
kept  up  for  some  time  after  apparent  cure, 

as  relapses  are  the  rule,  and  can  only  be 

,     1   .      ^1  .  Fig.    116.— Pedicultts.     a,   Nit 

averted  m  this  way.  attached  to  hair. 

Pediculi  Pubis.— These  parasites  may 
be  found  upon  the  scrotum,  as  they  may,  in  fact,  upon  any  part  of  the 
body  from  which  the  hairs  of  puberty  grow.  They  exist  in  greatest 
abundance,  however,  about  the  genitals,  and  particularly  on  the  mens 
veneris.  They  are  plainly  visible  to  the  naked  eye,  as  are  their  eggs 
attached  to  the  hairs  (Fig.  116). 

Mourson,^  a  French  naval  surgeon,  first  pointed  out  the  relation 
between  certain  blue  spots  on  the  skin  and  pediculi  pubis,  and  Douguet 
confirmed  the  relationship  by  inserting  a  bruised  pediculus  under  the 
skin  and  producing  a  spot.  Mallet  proved  that  the  coloring  matter 
resides  in  the  salivary  glands  of  the  pediculus. 

No  treatment  is  better  than  the  old-fashioned  blue  mercurial  oint- 
ment, which  may  be  rubbed  into  the  hairy  parts  about  the  pubes  and 
perineum  and  somewhat  down  the  thighs,  the  patient  going  to  bed  in 
drawers  and  sleeping  covered  with  the  ointment  all  night.  Two  such 
applications,  at  a  few  days'  interval,  usually  destroy  the  colony.  The 
treatment  is  a  very  dirty  one,  and  much  soap  and  hot  water  form  essen- 
tial parts  of  it. 

INJURIES  OF  THE  SCROTUM 

Wounds.--Wounds  of  the  scrotum,  whether  surgical  or  accidental, 
give  rise  to  free  bleeding.     This  must  be  entirely  controlled  by  ligature 
*  Lancet,  1882,  ii,  454. 


1,52  DISEASES  OF  THE  SCROTUM 

before  the  wound  is  sutured,  for  in  the  lax  scrotal  tissues  an  insig- 
nificant oozing  may  give  rise  to  an  enormous  hematoma  extending  to 
penis,  thighs,  and  abdomen. 

As  a  further  precaution,  the  scrotum  should  be  compressed  beneath 
the  adhesive  plaster  dressing  described  on  p.  575. 

Loss  of  Tissue.- — When  any  considerable  portion  of  the  scrotum 
is  destroyed  by  gangrene,  accident,  or  the  knife,  the  rapidity  with 
which  the  defect  covers  in  is  little  less  than  marvelous. 

Castration  need  never  be  performed,  however  great  the  loss  of  in- 
tegument. Kocher's  ^  case,  in  which  both  testicles  were  practically 
covered  over  by  skin  in  the  short  space  of  three  weeks,  shows  what 
brilliant  results  may  be  obtained  by  expectant  treatment.  The  surgeon 
need  only  help  with  tension  sutures  and  aseptic  dressings. 

Hematoma  and  Hematocele. — Contusions  of  the  scrotum  give  rise 
to  extensive  ecchymosis  and  edema  quite  comparable  to  the  familiar 
black  eye.  If  seen  early  the  hemorrhage  may  be  checked  by  adhesive 
plaster  compression  and  an  ice-cap.  Later  heat  promotes  absorption. 
The  hematoma  may  have  to  be  incised. 


INFLAMMATIONS  OF  THE  SCROTUM 

Inflammatory  Edema. — Extensive  edema  may  complicate  any  in- 
flammation of  the  scrotum  on  account  of  the  laxity  of  its  tissue. 

Where  edema  is  excessive,  and  the  tension  so  great  that  injury  to 
the  skin  seems  imminent  from  pressure,  a  few  punctures  may  be  made 
on  each  side  of  the  raphe,  at  the  most  dependent  point  of  the  scrotum. 
These  punctures  should  be  protected  by  a  wet  dressing  to  encourage 
oozing,  to  improve  the  circulation,  and  to  prevent  infection.  In  milder 
cases,  strapping  (p.  575)  will  quickly  reduce  the  edema,  if  the  cause 
has  been  removed  and  a  suspensory  bandage  is  applied. 

Cellulitis  and  Abscess — Cellulitis  and  abscess  of  the  scrotum  are 
encountered  clinically  as  phenomena  of  urinary  infiltration   (p.  265). 

Erysipelas. — Scrotal  erysipelas  is  peculiarly  virulent. 

In  the  beginning,  the  rapidity  of  invasion  and  the  superficial  nature 
of  the  lesion  distinguish  it  from  urinary  infiltration.  Later  the  two 
closely  resemble  each  other. 

Treatment. — Multiple  free  incisions  parallel  to  the  raphe,  and 
1  per  cent  carbolic  acid  wet  dressings  should  be  employed. 

Gangrene — Gangrene  of  the  scrotum,  whether  due  to  urinary  in- 
filtration, infection,  or  injury,  usually  involves  the  greater  part  of  the 
scrotum.  The  testicles  are  always  spared  and  swing  bare  and  bald. 
Coenen  ^  has  collected  206  cases  with  a  mortality  of  one  in  five. 

*"  Deutsche  Chirurgie,"  1887,  1  (b),  8.         '  Beitr.  s.  TcUn.  Chir.,  August,  1911. 


ELEPHANTIASIS,  LYMPH  SCROTUM,  LYMPH  VARIX  553 

Treatment. — The  condition  is  desperate  unless  immediately  sub- 
mitted to  the  knife.  All  the  gangrenous  tissue  must  be  cut  away  (the 
urethra  opened  and  the  bladder  drained  by  a  perineal  tube  if  there  is 
stricture),  and  the  testicles  supported  in  wet  dressings.  Castration  is 
never  indicated. 

The  skin  of  the  scrotum  heals  with  such  marvelous  rapidity  that 
plastic  operations  are  rarely  necessary. 

Diphtheria — Le  Clerc  ^  has  observed  and  collected  a  number  of 
cases  resembling,  clinically,  an  acute  erysipelas,  and  which  he  attributes 
to  diphtheria,  the  Klebs-Loeffler  bacillus  having  been  cultivated,  either 
pure  or  in  mixed  culture,  from  the  wound  discharges. 

Emphysema — This  occurs  with  general  subcutaneous  emphysema 
and  with  scrotal  gangrene. 

Scrotal  Fistula  and  Calculi — These  are  of  urethral  origin. 


ELEPHANTIASIS,  LYMPH  SCROTUM,  LYMPH  VARIX 

Elephantiasis  is  a  condition  of  chronic  distention  of  the  lymph 
vessels  of  any  part  of  the  body,  whereby  the  skin  and  subcutaneous 
tissues  become  thickened  and  indurated  and  the  part  often  enlarges 
to  an  incredible  size.  It  occurs  usually  in  the  lower  extremity  and 
in  the  penis  and  scrotum. 

Etiology. — The  cause  of  elephantiasis  is  obstruction  of  the  lymph 
channels.  Thus  scrotal  elephantiasis  may  follow  extirpation  of  the 
inguinal  glands.^  Severe  chronic  inguinal  adenitis  may  have  the  same 
unhappy  effect;  But  the  enormous  elephantiasis,  so  frequent  in  the 
tropics,  is  due  tiimost  always  to  the  filaria  sanguinis  hominis.  The 
fascinating  life  history  of  the  filaria  has  been  studied  by  Lewis,^  Man- 
son,*  Le  Dentu,^  Mastin/  Lothrop  and  Pratt,''^  and  many  others.  Born 
in  some  marsh  or  swamp,  the  embryo  enters  a  man's  alimentary  canal 
in  a  sip  of  water.  Thence  it  makes  its  way  to  the  lymphatics,  where 
it  settles  down  for  life  and  attains  its  full  development.  Here  it  is 
impregnated  and  pours  into  the  blood  current  an  infinite  stream  of 
embryos.  By  night  the  blood  is  alive  with  them,  by  day  not  one  can  be 
found  where,  a  few  hours  before,  were  myriads.  Where  they  hide  no 
one  knows.     But  in  the  human  host  they  cannot  develop.     To  reach 

^Guyon's  Annales,  1898,  xvi,  1102. 

*Cf.  Bull.  soc.  franqaise  de  dermai.  et  sypli.,  1898,  ix,  292. 
"'On  a  Hematozoon  Inhabiting  Human  Blood,"  1872,  Calcutta. 
*Med.  Times  and  Gazette,  1875,  ii,  542,  566;  Trans.  Path.  Soc,  1881,  xxxii,  285; 
Brit.  Med.  Jour,,  1899,  ii,  644. 

^ 'Revue  de  chir.,  1898,  xviii,  1. 

•Ann.  of  Surg.,  1888,  viii,  321. 

''Am.  Jour,  of  Med.  Sciences,  1902,  cxx,  525. 


554  DISEASES  OF  THE  SCROTUM 

maturity  they  must  be  sucked  up  by  a  mosquito — a  niglit-prowling 
insect.  The  mosquito,  gorged  with  blood,  returns  to  deposit  her  eggs 
and  die  in  his  (or  rather  her)  native  swamp,  where  from  her  corpse 
arise  the  filaria  ready  to  develop,  to  infest  the  water,  and  again  to  be 
swallowed  by  some  unsuspecting  man.^ 

So  much  for  the  romance.  The  sorry  fact  is  that  these  embryos, 
no  larger  than  a  leukocyte,  become  impacted  in  the  lymph  glands  or 
channels  in  such  a  way  as  slowly  and  progressively  to  obstruct  the 
lymph  flow.  If  this  happens  in  the  lower  inguinal  glands,  elephantiasis 
of  the  lower  extremity  results ;  if  in  the  upper  chain,  the  scrotum  and 
penis  are  affected;  if  in  the  iliac  glands,  lym-ph  varix  and  lymphade- 
noma  of  the  spermatic  cord  may  result. 

Chyluria  (or  hematochyluria)  and  chylous  hydrocele  are  caused  by 
rupture  of  a  dilated  lymphatic  vessel  into  the  cavit}^  of  the  urinary  tract 
or  into  the  tunica  vaginalis. 

Symptoms — Elephantiasis  begins  with  recurring  attacks  of  der- 
matitis and  edema  accompanied  by  fever.  At  iirst,  there  is  between  the 
attacks  only  a  brawny  patch  upon  the  skin  and  a  slight  enlargement  of 
the  inguinal  glands.  As  the  disease  progresses,  the  skin  and  subcu- 
taneous tissues  become  thickened  by  an  overgrowth  of  dense  fibrous 
elastic  tissue,  and  the  vessels,  especially  the  lymphatics,  become  enor- 
mously dilated.  As  the  scrotum  enlarges  it  drags  down  the  skin  of 
pubes  and  perineum  and  inverts  the  skin  of  the  penis,  leaving,  finally, 
no  trace  of  that  organ,  except  a  transverse  slit  on  the  anterior  surface 
of  the  tumor.  This  reaches  incredible  proportions.  Wilkes  removed  a 
scrotum  weighing  165  pounds,  and  Larrey  mentions  one  weighing  200 
pounds. 

Treatment. — The  prophylaxis,  avoidance  of  unboiled  drinking  water 
in  the  tropics,  need  scarcely  be  insisted  upon.  Curative  treatment  is 
surgical.  Fortunately,  ablation  of  the  hypertrophied  tissues  is  rarely 
followed  by  recurrence,  though  such  an  operation  does  not  pretend  to 
affect  the  mother  worm  or  her  ovulation.  The  chief  danger  of  operation 
is  the  bleeding.  This  was  successfully  controlled  in  an  operation  for 
vulvar  elephantiasis,  at  which  I  had  the  pleasure  of  assisting,  by 
Wyeth's  hip  pins  and  an  Esmarch  bandage.^  It  is  essential  to  re- 
move as  much  as  possible  of  the  indurated  tissue,  and  yet  to  leave 
flaps  to  cover  the  testicles  and  penis.  Radical  cure  of  hernia  may 
also  be  required.  The  strictest  asepsis  should  be  observed  to  avoid 
lymphatic  absorption.  In  the  smaller  cases  the  ing-uinal  glands  may 
be  removed. 

*  Of  late  years  there  is  a  tendency  to  consider  the  mosquito  the  adequate  inter- 
mediate host,  as  is  the  case  in  malaria.  I  have  sketched  the  classic  theory,  although 
it  will  perhaps  be  proved  incorrect. 

'Bullard,  Med.  Secord,  1899,  Iv,  128. 


TUMORS  OF  THE  SCROTUM 


555 


TUMORS  OF  THE  SCROTUM 


Cysts. — Small  sebaceous  cysts,  shining  white  through  the  distended 
skin,  occur  on  any  part  of  the  scrotum,  but  particularly  on  the  raphe. 
They  sometimes  attain  startling  dimensions.  Echinococcus  cysts  have 
been  met  with.  A  urinary  pocket  opening  into  the  urethra  behind  a 
stricture  has  been  mistaken  for  hydrocele.  Jacobson  gives  a  detailed 
account  of  two  cases  of  cystic  disease  of  the  scrotum,  to  which  Tilden 
Brown  ^  has  added  a  third. 

Multiple  minute  blood  cysts,  vary- 
ing in  size  up  to  that  of  a  large  pinhead, 
and  sprinkled  abundantly  over  the  en- 
tire scrotum,  are  sometimes  found  after 
middle  life.  They  are  of  a  dark-blue 
color  and  give  rise  to  no  changes  in  the 
skin  and  to  no  symptoms  whatsoever, 
excepting  their  appearance,  which  an- 
noys the  patient.  They  may  be  cured 
permanently  by  touching  each  one  sep- 
arately with  an  electrocautery,  or  prick- 
ing it  and  touching  the  raw  surface 
with  a  nitrate  of  silver  point. 

Cases  of  angioma,  angiokeratoma/^ 
fibroma,  lipoma,  fihromyxoma,  osteo- 
chondroma, an(;l  sarcoma  have  been  reported. 

Epithelioma  of  the  Scrotum  (Chimney-Sweeps  Cancer). — Soot 
seems  to  be  the  exciting  cause  of  scrotal  epithelioma  (Fig.  117)  in 
England,  although  in  other  countries  those  whose  occupation  brings 
them  into  contact  with  this  substance  do  not  seem  to  suffer.  Thus 
Warren  ^  states  that  he  has  seen  it  a  few  times  in  this  country,  but 
never  among  chimney-sweeps.    I  have  seen  but  three  cases. 

The  disease  begins  as  one  or  more  small,  soft  warts  or  tubercles, 
usually  at  the  lower  forepart  of  the  scrotum.  These  remain  unchanged 
for  a  time,  but  finally  indurate  slightly,  become  excoriated,  scab  over, 
and  ulcerate,  the  ulcer  extending  backward,  and  destroying,  with  more 
or  less  rapidity,  the  whole  scrotum.  The  ulcer  has  hardened,  irregular, 
purplish,  everted,  knotty  borders ;  a  hard,  uneven,  unhealthy  looking 
base. 

Exceptionally  the  warty  growth  develops  into  a  large  cauliflower- 
like mass  (Fig.  118). 

^Jour.  of  Ch'tt.  and  Gen.-Urin.  Diseases,  1895,  xiii,  33. 
'Sutton,  Jour.  A.  M.  A.,  1911,  Ivii,  189. 
""Surgical  Observations    ou  Tumors,"   p.  329, 


Fig.  117 — Epithelioma  of  the  Scro- 
tum IN  A  Paraffin  Worker. 
Three  ulcers  on  the  right  buttock. 


556 


DISEASES  OF  THE  SCROTUM 


Death,  occurs  by  exhaustion,  or  by  hemorrhage,  if  a  large  vessel 
be  severed  by  the  advancing  ulceration.     The  disease  continues  local 


Fig.  118. — Scrotal  Epithelioma. 


for  some  time.     It  is  only  tardily  that  the  ingTiinal  glands  become 
involved. 

Treatment. — Kadium  or  x-ray  may  cure  early  cases.  Large  lesions 
require  surgery  of  the  most  radical  sort — with  extirpation  of  the 
inguinal  glands. 


CHAPTEE    LVIII 

ANATOMY,  PHYSIOLOGY,  EMBRYOLOGY,  AND  ANOMALIES  OF  THE 

TESTICLE 

ANATOMY 


The  testicles  (Fig.  119),  each  suspended  by  its  spermatic  cord,  lie 
loosely  in  the  scrotum^  surrounded  by  connective  tissue.  The  left 
usually  hangs  lower  than  the  right.  The  mean  dimensions  of  the 
testicle  (Curling)  a  r  e  If 
inches  long,  1|  inches  antero- 
posteriorly,  and  1  inch  later- 
ally. Two  of  the  envelopes  of 
the  cord,  the  cremaster  mus- 
cle and  the  infundibuliform 
fascia,  also  cover  the  testicle, 
while  the  gubernaculum  at- 
taches it  to  the  bottom  of  the 
scrotum. 

Tunica  Vaginalis.  —  The 
proper  coverings  of  the  testi- 
cles are  two — the  tunica  vagi- 
nalis and  the  tunica  albuginea. 
The  former  is  a  closed  serous 
sac,  investing  all  the  secreting 
portion  of  the  testicle,  except 
where  the  epididymis  is  at- 
tached behind  and  the  guber- 
naculum below.  It  dips  down 
posteriorly,  between  the  epi- 
didymis and  the  testicle.  On 
the  outer  side  the  tunica  vagi- 
nalis covers  and  closely  invests 
the  epididymis.  The  sac  ex- 
tends up  the  cord  to  a  greater 
or  less  extent. 

The  tunica  vaginalis  represents  a  portion  of  the  peritoneum  carried 
down  by  the  testicle  in  its  descent  from  the  abdomen.     Ordinarily,  at 

fi67 


Fig.  119. — Left  Tunica  Vaginalis  Opened;' 
Showing  Testis,  Epididymis,  etc.,  from 
Outer  Side.  1,  Organ  of  Girald^s;  2,  vaa 
deferens;  3,  globus  major  of  epididymis;  4,  6, 
tunica  vaginalis;  5,  testicle;  7,  hydatid  of  Mor- 
gagni.     (Quain.) 


558  THE  TESTICLE 

birth,  all  connection  between  its  cavity  and  that  of  the  peritoneum  is 
closed,  a  white,  fibrous  line  (habenula)  alone  marking  the  original  con- 
tinuity of  membrane.  Sometimes,  however,  the  opening  persists,  in 
which  case  congenital  hernia  is  likely  to  occur ;  or  the  communication 
may  be  a  narrow  canal,  open  to  the  passage  of  fluid  only ;  or  again,  par- 
tial obliteration  may  occur,  isolated  serous  sacs  being  left  along  the 
cord ;  finally,  it  more  often  happens  that  the  upper  aperture  is  closed, 
and  a  considerable  portion  below  remains  unobliterated,  so  that  the 
tunica  vaginalis  extends  for  some  distance  upward  in  front  of  the  cord. 
The  cavity  of  the  tunica  vaginalis  is  lined  by  pavement  epithelium, 
and  normally  contains  only  enough  fluid  to  lubricate  the  surfaces. 

Tunica  Albuginea. — The  tunica  albuginea  is  the  proper  investing 
membrane  of  the  secreting  portion  of  the  testicle.  In  its  substance  the 
branches  of  the  spermatic  artery  ramify  and  break  up,  to  be  distributed 
to  the  seminal  tubules  within.  It  is  composed  of  dense,  white,  fibrous 
tissue,  is  very  inelastic  (whence  the  pain  in  orchitis),  and  sends  tra- 
beculae  into  the  substance  of  the  testicle  to  break  it  up  into  compart- 
ments for  the  lodgment  of  the  tubuli  seminiferi.  It  forms  the  medi- 
astinum (corpus  Highmorianum)  above  and  behind,  where  the  vessels 
pass  to  and  from  the  testicle,  and  where  the  straight  tubes  come  out  to 
form  the  coni  vasculosi  in  the  head  of  the  epididymis. 

Glandular  Substance. — The  glandular  substance  of  the  testicle  con- 
sists of  innumerable  little  tubes  (tubuli  seminiferi)  closely  packed  in 
conical  segments  between  the  fine,  fibrous  septa  thrown  out  by  the 
tunica  albuginea.  The  number  of  these  cones  is  computed  to  be  from 
250  to  about  500,  and  their  combined  length  from  1,000  to  5,500  feet. 

They  consist  of  a  membrana  propria,  within  which  are  several  layers 
of  epithelial  cells,  the  outer  ones  polyhedral,  those  nearer  the  lumen 
spherical.  These  latter  are  known  as  spermatoblasts,  and  from  them 
the  spermatozoa  are  evolved.  Section  through  a  tubule  shows  the  stages 
of  this  process  by  which  the  cells  become  pear-shaped,  tailed,  and  finally 
full-fledged  spermatozoa. 

Issuing  from  the  apices  of  the  cones  the  tubes  unite  to  form  20  or 
30  tubes  (vasa  recta),  which  run  straight  into  the  fibrous  mediastinum, 
and  there  form  an  irregular  plexus  of  channels  with  no  proper  walls 
(rete  testis).  Issuing  hence  the  ducts,  now  known  as  vasa  efferentia, 
pierce  the  tunica  albuginea  to  form  the  epididymis. 

The  Epididymis. — The  epididymis  caps  the  testicle  proper  and 
skirts  its  posterior  border.  It  begins  above,  where  the  vasa  efferentia 
issue  through  the  tunica  albuginea.  These  canals  immediately  dilate 
and  collect  in  convoluted  cones  (coni  vasculosi),  forming  the  broadest 
pari;  of  the  epididymis,  the  head  or  globus  major,  which  lies  over  the 
top  of  the  testicle.  The  coni  vasculosi  all  empty  into  one  canal — ^the 
canal  of  the  epididymis,  which  forms  by  its  convolutions  the  central 


PHYSIOLOGY  559 

part  or  body  of  the  epididymis.  This  body  is  separated  from  the 
testicle  proper  by  the  culdesac  of  the  tunica  vaginalis.  Below,  the 
canal  of  the  epididymis  exhibits  further  convolutions.  At  this  point 
it  is  known  as  the  globus  minor,  or  the  tail  of  the  epididymis.  Connec- 
tive tissue  unites  it  to  the  testicle  to  this  point,  and  from  here  on  the 
canal  becomes  more  dense,  and  is  known  as  the  vas  deferens. 

The  little  supernumerary  diverticulum  (or  there  may  be  several), 
known  as  the  vas  aherrans  of  Haller,  when  present,  usually  empties  into 
the  canal  of  the  epididymis  at  this  point.  The  canal  of  the  epididymis 
is  furnished  with  ciliated  epithelium  whose  cilia  sweep  toward  the  vas 
deferens. 

There  exist  normally  upon  the  head  of  the  epididymis  several  little 
prominences,  solid  and  cystic,  known  as  the  hydatid  of  Morgagni,  or 
pediculated  hydatid,  the  corpus  innominatum  of  Giraldes,  and  the  non- 
pediculated  hydatids.  They  are  the  remains  of  the  wolffian  body  and 
of  the  duct  of  Miiller. 

The  Mood  supply  of  the  testicle  and  epididymis  is  derived  from  the 
spermatic  artery.  The  lymphatics  ^  empty  into  the  lumbar  (not  the 
inguinal)  glands. 

PHYSIOLOGY 

External  Secretion. — The  function  of  the  testicle  is  to  form  sper- 
matozoa, the  male  procreative  seed.  These  are  not  a  secretion,  but  an 
evolution  of  the  spermatoblasts  of  the  seminal  tubulus.  Thence  they 
issue  by  force  of  their  own  motility  to  the  epididymis,  where  their 
transit  is  hastened  by  the  ciliated  epithelium.  From  the  vas  deferens 
they  are  collected  in  the  seminal  vesicle  and  ampulla,  whence  they  are 
ejaculated  during  the  sexual  orgasm. 

Internal  Secretion. — The  so-called  internal  secretion  of  the  testicles 
has  been  studied  anew  of  late  years  in  connection  with  the  discussion 
over  the  propriety  of  castration  for  hypertrophy  of  the  prostate.  It  has 
long  been  known  that  the  testicles  are  essential  to  a  virile  adolescence, 
since  castration  in  infancy  produces  the  recognized  type  of  high-voiced, 
effeminate  eunuchs.  The  familiar  contrast  between  ox  and  bull,  horse 
and  stallion,  is  equally  to  the  point. 

This  internal  secretion  is  derived  from  cells  lying  in  the  stroma  of 
the  testicles,  between  the  tubules. 

Thaler  and  Kasai  have  made  systematic  studies  of  the  life  history  of  the 
interstitial  cells,  from  fetal  life  into  senescence.  They  have  shown  that  these 
elements  are  extremely  abundant  during  the  fourth  and  fifth  months  of  fetal 
life,  and  that  after  birth  they  rapidly  diminish  in  number  and  are  not  much 
in  evidence  until  the  time  of  puberty,  when  they  undergo  a  renewal  of  growth. 

^  Jamieson,  Lancet,  Feb.  19,  1910;  Hinman,  Jour.  A.  M.  A.,  1914,  Ixiii,  2009. 


560  THE  TESTICLE 

Mitoses,  however,  are  rarely  if  ever,  observed.  During  middle  life  they  remain 
approximately  constant,  according  to  Thaler,  or  diminish  somewhat  in  numbers, 
according  to  Kasai  (Pappenheimer  and  Schwartz)/ 


EMBRYOLOGY 

The  two  constituent  parts  of  the  testicle,  which  have  been  briefly 
described  above,  are  developed  separately  in  the  fetus.  The  epididymis 
is  formed  from  the  lower  part  of  the  wolffian  body,  and  its  duct  is  a 
continuation  of  the  wolffian  duct  to  the  lower  and  back  part  of  the  blad- 
der. Thus  the  epididymis  may  be  regarded  ^mbryologically  as  the 
lower  part  of  the  kidney.  As  such  Belfield  believes  it  a  secretory  organ 
and  as  liable  to  hematogenous  infections  (notably  primary  tuberculosis) 
as  the  kidney.  The  secreting  portion  of  the  testicle,  on  the  other  hand, 
is  formed  from  fetal  tissue  lying  in  front  of,  but  seemingly  independent 
of,  the  wolffian  body. 

The  Descent  of  the  Testicle — The  testicle  develops  in  front  of  the 
wolffian  body,  resting  upon  the  brim  of  the  true  pelvis  near  the  site  of 
the  future  inguinal  canal,  which  at  this  period  (fifth  month)  is  repre- 
sented by  the  processus  funiculovaginalis,  a  pouch  of  peritoneum  run- 
ning into  and  terminating  among  the  muscle  fibers  of  the  abdominal 
wall,  through  which  it  ultimately  extends  into  the  scrotum.  This  pouch 
offers  a  resting  place  into  which  the  testis  tends  to  work  its  way,  aided 
by  the  gubernaculum  testis,  a  fibromuscular  cord  attached  above  to  the 
testis,  epididymis^  and  spermatic  cord,  below  to  the  abdominal  wall,  the 
inner  surface  of  the  pubes,  the  bottom  of  the  scrotum,  the  perineum, 
^nd  by  a  few  fibers  to  the  thigh  over  the  saphenous  opening.  Guided, 
or  perhaps  pulled — the  point  is  disputed — by  the  gaibernaculum,  the 
testicle  settles  into  the  peritoneal  pouchy  and  with  it  sinks  gradually 
through  the  abdominal  wall  and  into  the  scrotum.  The  stronger  fibers 
of  the  gaibernaculum,  fastened  to  the  bottom  of  the  scrotum,  persist  in 
adult  life  as  a  fascial  band,  while  the  processus  funiculovaginalis,  in- 
verted by  the  descent  of  the  testis,  becomes  the  tunica  vaginalis.  The 
part  of  the  processus  above  the  testis  is  obliterated  by  adhesion  of  its 
opposed  surfaces,  beginning  at  both  ends,  above  at  the  internal  abdomi- 
nal ring,  below  quite  near  the  testicle.  When  adhesion  is  complete  only 
a  fibrous  cord,  the  liahenula,  remains. 

The  descent  of  the  testicle  into  the  scrotum  occurs  during  the  last 
six  months  of  intra-uterine  life."    Indeed,  in  10  per  cent  or  20  per  cent 

^N.  Y.  State  Jour,  of  Med.,  1910,  x,  548.  This  exhaustive  monograph  suggests 
that  other  internal  secretions  also  share  in  determining  'he  virile  characteristics. 

*Only  mammals,  and  not  all  of  them,  have  extra-abdominal  testes,  while  some 
mammals  retain  the  testes  within  the  abdominal  cavity,  except  during  the  rutting 
season,  when  they  become  congested  and  are  extruded  into  the  scrotum. 


ANOMALIES  OF  THE  TESTICLE  561 

of  all  children  tlie  testicles  are  still  in  the  abdomen  at  the  time  of  birth. 
In  most  of  these  the  testicles  descend  during  the  following  weeks,  but 
a  small  proportion  are  retained  for  years,  or  even  permanently.  The 
clinician  need  take  no  account  of  the  position  of  the  testicle  during 
the  first  year,  but  if  it  is  retained  for  longer  than  this  the  condition  is 
definitely  abnormal. 


ANOMALIES  OF  THE  TESTICLE 


Monod  and  Terrillon's  classification  of  anomalies  of  the  testicle  is 
the  following: 

Anomalies  in  development . 


-r  ,  I  In  excess Polyorchism. 

in  number. ..)  ,  , ,  a         i  • 

!  T.  fl  V   i-  I  Absence.  .  .  Anorcbism. 

.Deficient  -<^  „     .  „  t  • 

1^1  usion ....  Synorcnism. 

rin   excess.... Hypertrophy. 

I^Defieient Atrophy. 

TT    T  ,1  flneomplete  miaration .    Retention. 

.  ......  i' Undescended^^  .,  ,       •       ,•  -n  ^     • 

Anomalies  m  migration ...  ^  j^Abnormai   migration.    JLCtopia. 

Descended Inversion. 

I.  Anomalies  in  Development. — Polyorchism. — Though  many  in- 
stances of  supernumerary  testis  have  been  reported,  and  the  condition 
is  known  to  exist  in  the  lower  animals  (Jacobson),  the  alleged  instances 
in  man  have  proved  to  be  pedunculated  tumors,  encysted  hydrocele, 
omental  hernia,  or  have  lacked  the  proof  of  a  pathological  examination, 
with  the  exception, of  the  case  reported  by  Arbuthnot  Lane,^  in  which 
the  diagnosis  was  confirmed  by  a  microscopical  examination  of  the 
supernumerary  organ. 

AxoRCHisM. — The  testicle  may  be  lacking  on  one  or  both  sides. 
With  absence  of  the  testicle  is  associated : 

1.  Usually  absence  of  the  epididymis  and  part  of  the  vas,  or 

2.  Exceptionally,  entire  absence  of  the  seminal  duct  up  to  the 
vesicle,  or 

3.  Still  more  rarely,  the  testis  only  is  wanting,  while 

4.  The  testis  may  be  present  and  the  vesicle,  epididymis,  and  vas 
absent. 

During  life  anorchism  cannot  be  differentiated  from  abdominal 
cryptorchism,  except  by  operation.     I  have  never  seen  a  case. 

Synorchism. — Jacobson  cites  the  cases  of  Cruveilhier  and  Lock- 
wood,  the  one  in  an  adult,  the  other  in  a  fetus,  of  intra-abdominal  tes- 
ticular fusion. 

II.  Anomalies  in  Migration.  —  Cryptorchism.  —  Cryptorchism 
means  absence  of  one  or  both  testicles  from  the  scrotum,  and  their 

^Brit.  Med.  Jour.,  1894,  ii,   1241. 


562  THE  TESTICLE 

presence  elsewhere,  in  contradistinction  to  anorchism,  meaning  total 
absence.  Monorchism  is  unilateral  cryptorchism.  A  retained  testis  is 
one  that  has  been  arrested  at  some  point  in  its  normal  descent.  An 
ectopic  testis  is,  strictly  speaking,  one  that  has  lodged  at  some  point 
out  of  its  normal  course.  The  term  "ectopia  testis"  is  often  used  loosely 
as  a  synonym  for  cryptorchism. 

Cryptorchism  is  an  infrequent  anomaly.  Eccles  ^  reports  854  cases 
among  48,000  men  with  hernia,  Coley,"  737  among  59,235.  Marshall 
found  11  cases  among  10,800  recruits. 

Ketentiok. — By  obstruction  to  its  progress  or  by  traction  from 
behind  (peritoneal  adhesions)  the  testis  may  be  retained  inside  the 
abdomen,  or  it  may  be  arrested  at  any  point  in  its  descent.  Hence 
there  may  be:  (1)  Abdominal  retention,  the  testis  lying  in  the  lumbar 
region,  or  floating  attached  by  a  "mesorchium,"  or  resting  in  the  false 
pelvis  near  the  internal  abdominal  ring  (iliac  retention).  (2)  Inguinal 
retention,  the  most  common  variety,  the  testis  lying  in  the  inguinal 
canal.  (3)  Puboscrotal  retention,  the  testis  lying  just  under  the  pubic 
bone.  (4)  Rarely  the  testicle  alone  is  retained,  while  the  epididymis 
and  vas  are  separated  from  it  and  descend  normally  into  the  scrotum. 

The  position  of  the  retained  organ  is  only  relatively  fixed.  It  has 
a  certain  range  of  motion,  sometimes  so  great  as  to  leave  the  classifica- 
tion doubtful.  A  severe  strain  may  cause  retraction  into  the  inguinal 
canal  of  a  testicle  that  had  been  supposed  to  be  normal. 

Ectopia. — Abnormal  tension  of  some  of  the  accessory  bands  of  the 
gubernaculum  may  drag  the  testis  out  of  its  normal  course:  (1)  into 
the  perineum,^  where  it  lies  beneath  the  deep  fascia,  in  front  of  the 
anus  (among  Coley's  737  cases  only  15  were  perineal)  ;  or  (2) 
through  the  crural  canal  to  the  saphenous  opening  (very  rare)  ; 
or  (3)  into  the  opposite  side  of  the  scrotum  (cases  of  Jordan* 
and  von  Lenhossek)  ;  or  (4)  to  the  front  of  the  pubis  at  the  base  of  the 
penis  (2  cases  of  Popow  ^). 

iNVEKSioisr. — The  testicle  may  be  turned  upside  down  in  the  scro- 
tum, or  rotated  so  that  its  long  axis  is  horizontal  or  abnormally  attached 
to  the  epididymis  (cf.  Jacobson).  The  only  clinical  significance  of 
these  very  rare  anomalies  is  their  bearing  on  puncture  of  hydrocele, 
for  the  inverted  testis  may  lie  above  and  in  front  of  instead  of  below 
and  behind  the  tunica  vaginalis. 

Condition  of  the  Testicle.-^The  retained  testicle  is  likely  to  be 
small  and   its  spermatogenetic  function  impaired.      The  interference 

^Lancet,  1902,  i,  569,  722. 

'Ann.  Surg.,  1908,  xlviii,  321. 

»Cf.  Loewe,  Jour.  A.  M.  A.,  1915,  Ixv,  No.  14. 

*Deutsch.  med.  Wochenschr.,  1895,  xxi,  525, 

'Bull,  dc  la  soc,  miat.,  1888,  v,  ii,  653. 


ANOMALIES  OF  THE  TESTICLE  563 

with  gTOwth  and  function  is  proportionate  to  the  pressure  to  which 
the  testicle  is  subjected.  Thus  so  long  as  the  testicle  is  outside  the 
inguinal  canal  its  development  is  not  likely  to  be  very  gravely  inter- 
fered with. 

The  spermatogenetic  function  does  develop,  however,  though  a 
little  late,  in  most  of  the  testicles  that  do  not  show  any  definite  deformity 
of  epididymis  or  vas  (and  even  in  some  of  these).  Examination  of 
such  an  organ  shortly  after  puberty  will  show  the  tunica  albuginea  and 
the  interstitial  tissue  of  the  testicle  abnormally  developed  while  the 
parenchymatous  cells  are  proportionately  much  more  numerous  than  the 
spermatogenetic  cells  (Odiorne  and  Simmons).^  After  puberty  the 
spermatogenetic  function  is  soon  lost ;  so  soon  indeed  that  Bland-Sut- 
ton -  derides  the  surgeon's  effort  to  save  the  retained  testicle  by  replac- 
ing it  in  the  scrotum. 

Fortunately  the  growth  of  the  interstitial  cells  is  much  less  im- 
peded than  that  of  the  spermatogenetic  cells  so  that,  as  a  rule,  even 
abdominal  retention  of  both  testicles  does  not  interfere  with  virile 
development. 

A  great  majority  of  double  cryptorchids  are  sterile,  and  so  general 
is  the  application  of  this  rule  that  Curling,^  after  citing  several  cases 
of  women  married  to  cryptorchids  bearing  one  or  several  children,  felt 
compelled  to  doubt  the  paternity.  But  several  similar  cases  have  been 
reported  since,  a  notable  one  by  Milner  Smyth,*  whose  patient  begot 
five  children,  and  the  question  is  seemingly  closed  by  the  observations 
of  Beigel  ^  and  of  Valette.^  The  former  found  numerous  spermatozoa 
in  the  semen  of  a  double  cryptorchid  aged  twenty-two.  The  latter  found 
a  few  in  the  retained  testicle  removed  from  a  man  twenty-one  years 
old. 

In  determining  the  sterility  of  any  given  patient  several  points 
must  be  taken  into  consideration. 

1.  The  position  of  the  testicles,  since  all  abdominal  cryptorchids 
appear  to  be  sterile. 

2.  Freedom  from  previous  or  present  inflammation, 

3.  The  size,  consistence,  sensitiveness,  motility  and  abnormality  of 
the  testicle,  and 

4.  The  age  of  the  patient.  All  the  cryptorchids  to  whom  children 
have  been  attributed  were  young  men.  The  period  of  possible  paternity 
is  apparently  not  over  five  or  ten  years. 

^Annals  of  Surgery,  December,  3904. 

'Practitioner,  January,  1910. 

»  Op.  cit.,  p.  467. 

*  Lancet,  1899,  ii,  785. 

'^  Virchow's  Archiv.,  1867,  xxxviii,  144. 

'Lyon  med.,  1869,  ii,  20.     Cf.  also  Schmidt,  Beitr.  s.  Uin.  Chir.,  1912,  Ixxxii,  36. 


564  THE  TESTICLE 

5.  A  definite  conclusion  is  impossible,  except  from  the  microscopi- 
cal examination  of  the  semen  for  spermatozoa. 

Complications  of  Ceyptorchism. — Pain  in  the  testicle  is  an  early 
evidence  that  the  surrounding  muscles  are  exerting  injurious  pressure 
upon  the  gland.  Injiammation,  whether  traumatic  or  gonorrheal,  is 
not  rare,  and,  if  acute,  is  exquisitely  painful.  Atrophy  follows.  Hy- 
drocele, gangrene,  abscess,  and  fatal  peritonitis  are  among  the  rarer 
consequences  of  inflammation. 

Hernia,  actual  or  potential,  always  accompanies  ingTiinal  retention, 
since  the  testicle  keeps  the  canal  patent.  Torsion  of  the  cord  occurs 
almost  exclusively  in  malposed  testicles. 

Malignant  growths  affect  the  retained  as  they  do  the  descended  tes- 
ticle (p.  594).  The  tradition  that  the  retained  testis  is  peculiarly  liable 
to  cancer  was  first  disputed  by  Eccles.  With  this  opinion  subsequent 
authors  do  not  concur.     Buckley  ^  states  that : 

About  one  in  four  eases  of  malignant  abnormally  situated  testicles  is  found 
within  the  abdomen  ;  one  malignant  abdominal  testicle  occurs  to  each  15  malignant 
scrotal  testicles;  about  one  in  each  75  abdominally  retained  testes  will  become 
malignant. 

Cases  occur  mainly  during  the  years  of  greatest  sexual  acti%dty;  they  may 
occur  in  apparent  females,  and  are  slightly  more  frequent  on  the  right  side. 

The  structure  of  the  tumors  differs  markedly,  but  most  of  them  are  prob- 
ably teratomata. 

Symptoms  do  not  occur  until  the  size  of  the  tumor  or  its  metastases  cause 
pressure. 

The  prognosis  is  bad.  Of  50  cases  reported  only  3  are  known  to  be  alive 
and  well  after  two  years. 

Prognosis. — Spontaneous  descent  of  the  testicle  may  not  be  looked 
for  after  the  first  year  in  any  large  proportion  of  cases.  A  sudden 
muscular  effort  caused  spontaneous  descent  of  the  testicles  of  a  man 
thirty-three  years  old  (Landouzy),  but  this  is  a  most  exceptional  case. 
Ambrose  Pare  has  left  an  amusing  account  of  one  Marie  Germain  who 
jumped  a  ditch  in  chasing  her  pigs  when,  feeling  a  sharp  pain  and 
"seeing  her  genitals  develop/'  "sen  retourne  larmoyante  en  la  maison 
de  sa  mere  disant  que  ses  tripes  lui  estoient  sorties  hors  du  ventre," 
whereupon  her  true  sex  was  recognized  and  she  became  a  man. 

In  general  the  prognosis  of  retained  testis  is  "atrophy,  perhaps 
sarcoma." 

Treatment. — During  infancy  every  effort  should  be  made  by  pad 
and  truss  to  encourage  the  testicle  to  descend.  Success  is  possible  up 
to  the  tenth  year.  Armstrong  -  alleges  that  in  three  out  of  four  boys 
V6  years  of  age  in  whom  no  testicles  could  be  felt  the  administration  of 

'  Surg.,  Gynec.  and  Obstet.,  1913,  xxii,  704. 
*  Med.  Press  and  Circ,  Aug.  4,  1915. 


ANOMALIES  OF  THE  TESTICLE  565 

tlivroid  extract  led  to  the  descent  of  these  glands  into  the  scrotum  within, 
three  months. 

If  such  treatment  does  not  effect  reduction,  the  testicle  may  be 
allowed  to  remain  where  it  is,  or  operation  may  be  performed  to  drag 
it  down  or  to  extirpate  it.  If  there  is  pain  or  hernia,  this  attempt 
should  certainly  be  made  and  the  testicle  sacrificed  if  it  cannot  be 
brought  down.  Broca  ^  has  succeeded  in  bringing  down  138  such  tes- 
ticles without  a  death.  Of  79  cases  observed  for  over  a  year  31  had 
apparently  normal  testicles,  35  had  testicles  normal  in  quality,  but 
abnormal  in  position  (near  the  external  ring),  while  in  only  13  had  the 
gland  atrophied.  In  1  case  the  abdominal  wall  remained  weak,  and  in 
no  case  was  there  any  recurrence  of  pain.  Only  once  was  castration 
required. 

"The  operation  should  not  be  attempted  before  the  eighth  year  nor 
delayed  beyond  the  twelfth"  (Coley^). 

When  this  operation  fails,  castration  is,  in  most  instances,  prefer- 
able to  abdominal  reposition,  which  subjects  the  gland  to  the  very 
dangers  (except  hernia)  to  be  avoided. 

"^Gaz.  Hebdom.,  1899,  iv,  289,  and  Gas.  des  hop.,  1899,  Ixxii,  315. 
^Ann.  of  Surg.,  1908,  xlviii,  321. 


CHAPTER   LIX 
INFLAMMATIONS  OF  THE  TESTICLE  AND  EPIDIDYMIS 

iNFLAMMATiOisr  of  the  testicle  may  be  limited  to  the  epididymis 
(epididymitis),  or  may  attack  the  secreting  structure  only  (orchitis). 
The  secreting  structure  may  become  secondarily  involved  by  a  simple 
inflammation  commencing  in  the  epididymis,  but  the  latter  rarely  suf- 
fers as  a  result  of  orchitis.  The  tunica  vaginalis,  lying  close  to  the 
epididymis,  becomes  inflamed  in  most  cases  of  epididymitis,  constitut- 
ing acute  hydrocele.  On  the  other  hand,  hydrocele  is  rare  with  orchitis, 
since  the  dense  tunica  albuginea  prevents  an  inflammation  originating 
on  one  side  of  it  from  being  readily  transmitted  to  the  other. 

Etiology. — Inflammations  of  the  testicle  may  arise  by: 

1.  Infection  passing  along  the  seminal  canals  from  the  urethra. 

2.  Infection  from  the  blood  or  the  lymph. 

3.  Trauma. 

1.  To  the  first  class  belong  simple  inflammatory  and  gonorrheal  in- 
fections ;  they  involve  the  epididymis  only.  Tuberculosis  probably  be- 
longs here  (though  it  attacks  the  testis  secondarily). 

2.  To  the  second  class  belong  syphilitic  inflammations  (usually 
beginning  in  the  testicle)  and  the  orchitis  of  infectious  diseases. 

3.  Inflammations  of  the  third  class  (traumatic)  implicate  both  testis 
and  epididymis,  but  chiefly  the  former. 

EPIDIDYMITIS 

Epididymitis  is  the  most  common  of  all  the  diseases  of  the  testicle. 
It  occurs  at  any  age,  most  frequently  during  early  adult  life  and  middle 
age,  since  its  chief  cause — urethral  inflammation  or  irritation — exists 
most  commonly  during  these  periods  of  life.  It  is  usually  acute,  but 
may  be  subacute  from  the  first.  It  habitually  terminates  in  resolution, 
rarely  in  abscess.  One  attack  predisposes  to  another.  It  is  often 
double,  but  the  inflammation  of  one  testicle  usually  precedes  that  of  the 
other.     Relapse  is  not  uncommon. 

ETIOLOGY 

The  prime  cause  of  epididymitis  is  inflammation  of  the  posterior 
urethra.    The  inflammation  travels  from  the  urethra  up  the  ejaculatory 

666 


EPIDIDYMITIS  567 

duct  and  along  the  vas  deferens  by  extension  of  tlie  inflammation  along 
the  lymphatics  of  these  canals.  This  explanation  has  been  disputed,  but 
three  facts  prove  it : 

1.  'No  matter  what  the  condition  of  the  anterior  urethra,  epididy- 
mitis never  occurs  except  from  inflammation  or  trauma  of  the  posterior 
urethra. 

2.  The  prodromal  symptoms  often  point  to  inflammation  of  the 
vas  before  there  is  inflammation  of  the  epididymis. 

3.  Vasotomy  ^  has,  in  my  experience,  cured  the  most  inveterate 
cases  of  relapsing  epididymitis. 

Gonorrhea. — Epididymitis  is  to  be  looked  for  mainly  from  the  third 
to  the  eighth  week  of  gonorrhea.  A  number  of  cases  are  on  record  in 
which  it  is  alleged  that  epididymitis  has  preceded  the  gonorrheal  out- 
break (Fourneaux- Jordan,  Sturgis,  Stansbury,  Castelnau,  Vidal). 
Such  an  occurrence  can  only  be  explained  by  the  existence  of  antecedent 
posterior  urethritis  or  spermatocystitis. 

Some  individuals  seem  predisposed  to  epididymitis,  so  that,  not- 
withstanding the  utmost  care,  every  attack  of  gonorrhea  is  invariably 
attended  by  swelled  testicles;  while  others,  regardless  of  all  hygienic 
precautions,  go  about  with  a  raging  gonorrhea,  employing  no  treatment, 
continuing  sexual  intercourse  and  the  abuse  of  alcohol,  not  even  sup- 
porting the  testicles,  and  yet  escape.  Indeed,  the  one  patient  who 
took  more  scrupulous  care  of  himself  than  any  other  in  my  whole  ex- 
perience, who  went  to  bed  and  stayed  there,  took  no  local  treatment 
whatever,  and  lived  on  the  lightest  of  diets,  in  due  time  developed  a 
double  epididymitis,  which  terminated  in  suppuration  on  both  sides. 

It  may,  however,  be  stated  dogmatically  that  while  a  gonorrhea  of 
itself  will  sometimes,  in  spite  of  all  precautions,  occasion  swelled  tes- 
ticles, yet  this  complication  is  not  likely  to  ensue  if  the  patient  wear  a 
suspensory  bandage,  abstain  from  violent  or  jolting  exercise  (horseback 
riding,  dancing) ,  sexual  excitement  and  the  use  of  alcohol.  The  passage 
of  instruments  through  a  canal  subject  at  the  time  to  gonorrhea  is  a  suf- 
ficient cause  for  epididymitis.  The  local,  and  especially  the  abortive, 
methods  of  treatment  are,  therefore,  peculiarly  liable  to  occasion  swelled 
testicle.  Yet  the  modern,  moderate  local  treatment,  if  promptly  applied 
and  properly  administered,  is  the'one  way  to  prevent  posterior  urethritis, 
epididymitis,  and  all  the  other  complications  of  gonorrhea. 

Non-gonorrheal  Infection. — The  peculiar  characteristics  of  non- 
gonorrheal  epididymitis  occurring  in  the  course  of  stricture  and  pros- 
tatism have  long  been  recognized.  Two  other  facts  have  escaped  notice 
however.  In  the  first  place,  epididymitis  may  occur  in  the  absence  of 
gonorrhea  or  of  any  urethral  obstruction.  It  is  due  to  infection  of 
the  seminal  vesicle  and  exhibits  certain  striking  differences  from  gon- 

^Cf.  Chetwood,  Jour.  of.  Cut.  and  Gen.-Urin.  Diseases,  1900,  xviii,  .445, 


568       INFLAMMATIONS  OF  THE  TESTICLE  AND  EPIDIDYMIS 

orrheal  epididymitis.  Furthermore,  epididymitis  occurring  in  the 
course  of  a  gonorrhea  but  similar  in  type  to  this  non-gonorrheal  infec- 
tion is  usually  not  due  to  the  gonococcus. 

The  bacterial  cause  is  usually  a  staphylococcus,  rarely  a  streptococ- 
cus, B.  coli,  B.  lactis  aerogenes,  etc.  Smears  and  cultures  are  often 
negative. 

PATHOLOGY 

Gonorrheal  Infection. — Typical  gonorrheal  epididymitis  begins  in 
the  globus  minor  as  an  acute  inflammation  that  always  proceeds  to  the 
formation  of  pus,  but  the  pus  foci,  though  multiple,  rarely  contain 
more  than  a  few  drops  of  pus.  If  mild  the  infection  remains  confined 
to  this  end  of  the  epididymis.  If  severe  it  may  extend  throughout  the 
organ,  producing  similar  miliary  abscesses  at  various  points,  while  the 
whole  epididymis  becomes  infiltrated,  swollen  and  red.  The  testicle 
takes  no  fart  in  the  injiaynmation,  but  the  tunica  vaginalis  may  be 
acutely  inflamed,  and  hydrocele  may  result.  The  hyperacute  case  com- 
bines an  intensely  swollen  epididymis,  an  acute  hydrocele,  and  con- 
siderable edema  of  the  cellular  tissue  about  the  testicle  so  that  this 
feels  like  an  evenly  swollen  hard  sensitive  mass.  The  vas  deferens  may 
share  in  a  severe  inflammation  to  the  extent  of  a  sensitiveness  and 
slight  thickening;  but  the  deferentitis  does  not  show  the  virulence 
characteristic  of  non-gonorrheal  infection. 

Non-gonorrheal  Infection — Infection  with  bacteria  other  than  the 
gonococcus  may  occur  during  a  gonorrhea.  Indeed  inasmuch  as  smears 
and  cultures  are  often  negative  it  is  difficult  to  distinguish  the  limita- 
tions of  the  two  types  of  inflammation.  The  typical  non-gonorrheal 
case  follows  one  of  two  types: 

1.  The  pseudotuberculous  type.  The  inflammation  begins,  often  in 
a  patient  with  no  history  of  antecedent  urethral  lesion,  as  a  chronic 
inflammatory  nodule  in  the  globus  minor,  but  slightly  tender  and 
causing  no  constitutional  disturbance.  It  passes  for  tuberculosis  until, 
quite  spontaneously,  it  disappears,  leaving  a  scarcely  perceptible  thick- 
ening of  the  epididymis. 

2.  The  inflammation  begins,  not  in  the  epididymis  at  all,  but  in 
the  seminal  vesicle  and  vas  deferens.  There  may  be  stricture,  pros- 
tatism, chronic  posterior  urethritis  or  the  infection  may  begin  inde- 
pendently of  any  known  preceding  lesion.  At  the  outset  the  vesicle 
becomes,  not  only  large,  but  thickened  and  finally  of  a  wooden  hard- 
ness and  much  thickened.  There  may  be  abscesses  in  the  vesicle  or 
in  the  adjacent  prostatic  lateral  lobe,  but  these  are  uncommon;  the 
vesicle  usually  feels  about  the  size  of  the  little  finger,  and  is  not  very 
sensitive.  From  the  vesicle,  the  inflammation  advances  along  the  vas 
as  a  perideferentitis,  the  whole  cord  becomes  thick,  sensitive,  adherent. 


EPIDIDYMITIS  569 

It  usually  reaches  the  size  of  a  lead  pencil  and  may  be  twice  as  large. 
The  pi'ogress  of  the  inflammation  may  sometimes  be  followed  day  by 
day  as  it  advances  down  the  vas  toward  the  epididymis.^  The  tendency 
of  this  infection  is  to  result  in  abscess  either  in  the  epididymis  or  at 
the  external  abdominal  ring. 

The  Decline. — The  gonorrheal  and  non-gonorrheal  infections  differ 
very  markedly  in  their  decline.  The  former,  however  acute,  and  al- 
though they  always  lead  to  miliary  abscesses  in '  the  epididymis,  very 
rarely  terminate  in  gross  suppuration.  Expectant  treatment  will,  almost 
always,  promptly  cure  them.  Within  a  few  weeks  the  major  part 
of  the  edema  is  absorbed,  and  there  remains  only  a  knot  of  scar  at  a 
point  where  the  suppuration  has  been. 

But  the  termination  of  non-gonococcic  infection  is  much  more 
grave.  Fortunately  abscess  within  the  pelvis  is  rare.  But  abscess  of  the 
vas  in  the  upper  part  of  the  scrotum,  and  abscess  in  the  globus  minor 
of  the  epididymis,  are  both  common  terminations.  If  gross  suppura- 
tion does  not  occur  the  infection  may  hang  on  for  an  indefinite  period, 
and  if  it  finally  does  terminate  without  suppuration  relapses  are  ex- 
tremely common  as  compared  to  their  infrequency  in  truly  gonorrheal 
infection  (unless  the  patient  acquires  a  new  gonorrhea). 

Rare  T3rpes  of  Infection. — I  have  once  seen  a  truly  fulminating 
epididymitis.  Operation  revealed  miliary  abscesses  throughout  the 
epididymis,  and  resulting  gangrene  of  the  testicle  requiring  orchid- 
ectomy.     B.  coli  was  revealed  by  culture. 

Barney  ^  has  reported  cases  of  spontaneous  abscess  of  the  testicle 
without  evidence  of  primary  epididymitis.  He  obtained  by  culture  the 
colon  bacillus,  a  streptococcus  and  the  B.  mucosae  capsulatus. 

Ombredanne  ^  reports  several  cases  of  primary  suppuration  in  the 
testicle  in  children  which  he  attributes  usually  to  torsion. 

SYMPTOMS 

Gonorrheal. — Usually  the  urethral  discharge  is  not  visibly  modified 
until  after  the  testicle  begins  to  swell.  Then  it  diminishes,  perhaps 
stops,  to  return  again  as  soon  as  the  inflammation  of  the  epididymis  is 
fairly  on  the  decline. 

A  vague  uneasiness  is  sometimes  felt  in  the  testicle  and  along  the 
cord  up  into  the  back,  as  if  the  cord  were  being  pulled  upon.  Attentive 
patients  will  frequently  aver  that  the  pain  was  noticeable  in  the  groin 
for  some  hours  before  any  uneasiness  was  experienced  in  the  testicle. 

^  The  opposite  course  is  also  very  frequently  seen,  the  epididymis  being  involved 
first,  and  the  cprd  being  much  thickened  secondarily.  We  do  not  yet  know  whether 
this  secondary  deferentitis  is  usually  gonorrheal  or  usually  non-gonorrheal. 

''Surg.,  Gyn.  4-  Obstet.,  March,  1914,  307. 

'Presse  med.,  1913.  xxi,  595. 


570       INFLAMMATIONS  OF  THE  TESTICLE  AND  EPIDIDYMIS 

The  attack  then  begins  with  pain  and  swelling  of  the  epididymis. 
In  the  subacute  form,  tha  swelling  is  moderate,  comes  on  rather  slowly, 
and  is  confined  to  the  epididymis.  There  is  but  little,  if  any,  fluid  in 
the  tunica  vaginalis.  There  are  no  constitutional  symptoms  and  the 
pain  is  not  excruciating.  It  is  aggravated  by  the  erect  posture,  but 
wholly  disappears  when  the  patient  is  put  on  his  back  with  the  testicle 
elevated. 

But  the  picture  is  a  different  one  if  the  onset  is  acute.  The  swell- 
ing commences  promptly  and  increases  with  rapidity.  Within  a  few 
hours  the  testicle  is  swallowed  up  in  the  exquisite  tension  and  tender- 
ness of  hyperacute  epididymitis  and  vaginalitis.  The  scrotal  tissues 
become  edematous.  The  inflamed  mass  rapidly  reaches  the  size  of  the 
fist.     The  cord  may  or  may  not  share  in  the  infection. 

Non-gonorrheal — One  must  distingiiish  the  case  in  which  the  epi- 
didymitis predominates  from  that  in  which  the  deferentitis  predomi- 
nates. The  former,  if  acute,  resembles  gonorrheal  epididymitis  but 
usually  terminates  in  gross  suppuration  resulting  in  an  abscess  which 
fills  the.  scrotum.  These  cases  should  be  operated  upon  just  as  soon 
as  it  is  evident  that  palliative  treatment  is  not  going  to  control  them. 

The  subacute  cases  of  the  epididymal  type  usually  simulate  tuber- 
culosis of  the  epididymis  very  closely.  The  patient  has  no  gonorrhea, 
and  there  is  often  no  very  grave  lesion  in  the  prostate  or  seminal  ves- 
icles, though  these  organs  contain  pus.  It  is  likely  after  a  few  weeks 
to  recede  spontaneously  and  leave  but  a  very  small  scar  to  mark  its 
passage. 

The  type  of  epididymitis  in  which  inflammation  of  the  vas  pre- 
dominates is  described  above. 

Chronic  and  Relapsing  Epididymitis. — Any  of  the  acute  types  of 
epididymitis  described  above  may  dwindle  off  gradually  into  a  chronic 
condition,  usually  with  an  irregular  tendency  to  relapse.  The  relapses 
may  occur  in  an  epididymis  which  is  constantly  a  little  full  and  tender 
or  after  the  original  inflammation  has  apparently  subsided.  Gonococcic 
epididymitis  is  only  likely  to  relapse  if  a  new  infection  of  gonorrhea 
occurs ;  indeed,  unlike  gonorrheal  rheumatism,  many  a  person  has  an 
epididymitis  during  one  attack  of  gonorrhea,  and  none  during  subse- 
quent attacks.  But  non-gonorrheal  epididymitis  is  peculiarly  subject 
to  relapses  without  rhyme  or  reason  in  some  instances.  Relapses  are 
habitually  milder,  but  more  long  drawn  out  than  the  first  attack.  The 
only  relief  for  such  cases  is  drainage  of  the  suppurating  focus  and 
division  of  the  vas. 

DIAGNOSIS 

The  diagnosis  between  the  gonococcic,  the  non-gonococcic  and  the 
tuberculous  epididymitis  is  by  no  means  always  easy  until  the  condi- 


EPIDIDYMITIS 


571 


tion  has  existed  for  some  time.  Tuberculosis  is  essentially  chronic,  pro- 
gressive and  associated  with  lesions  in  the  internal  genitals  which, 
sooner  or  later,  reveal  their  tuberculous  nature.  The  only  way  to  dis- 
tinguish the  non-gonococcic  pseudotuberculosis  of  the  epididymis  in 
certain  cases  is  to  await  the  progress  of  the  disease.  If  it  is  not  due 
to  tuberculosis  it  will  disappear  spontaneously.  The  deferentitis  type 
is  often  mistaken  for  tuberculosis  simply  because  its  frequency  and 
characteristic  signs  are  not  generally  recognized.-^ 


FiQ.  120. — Abscess  in  Tail  of  Epididtmis;  Relapsing  Epididymitis. 


A  positive  complement  fixation  test  for  gonorrhea  does  not  prove 
that  an  epididymitis  is  wholly  due  to  the  gonococcus;  the  possibility 
of  error  is  indeed  a  small  one,  yet  I  fancy  that  certain  cases,  occur- 
ring during  a  gonorrhea,  and  with  a  complement  fixation  test  positive, 
are  due  to  a  mixed  infection  and  that  this  accounts  for  the  certain  cases 
of  marked  deferentitis  and  of  suppuration  following  a  gonorrheal  epi- 
didymitis. 

Acute  orchitis  is  distinguished  by  its  etiology,  the  more  marked  gen- 
eral symptoms,  and  the  fact  that  the  testis  proper,  and  not  the  epididy- 
mis, is  chiefly  involved. 

PROGNOSIS 

As  the  disease  advances,  pain  increases  in  intensity.  The  duration 
of  pain  and  swelling  depend  almost  exclusively  on  the  treatment.     This 

'  I  have  once  seen  a  true  tuberculosis  of  the  deferential  type. 


572       INFLAMMATIONS  OF  THE  TESTICLE  AND  EPIDIDYMIS 

should  control  fever  and  pain  immediately.  The  swelling  subsides 
more  slowly. 

The  gradual  disappearance  of  the  hardness  from  the  epididymis  may 
extend  over  many  months,  and  in  most  cases  is  never  entirely  accom- 
plished. The  point  first  attacked  is  the  last  to  resolve.  The  absorption 
starts  rapidly,  but  progresses  more  and  more  slowly,  until  it  seems  to 
remain  stationary.  The  little  hard  lump  in  the  epididymis  occasions 
the  patient  no  uneasiness,  is  not  sensitive  to  pressure,  and  is  ignored. 
Extensive  suppuration  is  rare  in  gonorrheal  epididymitis,  but  not  un- 
com.mon  in  severe  cases  due  to  other  bacteria.  Atrophy  of  the  testicle 
never  results. 

The  prognosis  may  be  summed  up  thus:  there  is  no  danger  to  life, 
to  sexual  potency,  or  to  desire.  ISTeuralgia  or  tuberculosis  may  follow 
acute  epididymitis  in  subjects  predisposed  to  these  ills.  Sterility  (of 
the  affected  organ)  and  relapse  are  both  possible  results,  but  the 
former  is  not  inevitable ;  the  latter  is  uncommon. 

Yet  the  patient  is  not  impotent,  his  sexual  power  and  appetite  are 
unimpaired.  He  ejaculates  semen  resembling  the  healthy  fluid  in  quan- 
tity, smell,  and  color,  but  containing  no  spermatozoa. 

Benzler's  ^  investigations  are  interesting  in  this  regard.  By  looking 
up  the  subsequent  history  of  old  soldiers  who  had  had  gonorrhea  while 
in  the  German  army,  he  found  that  among  those  who  had  been  married 
three  or  more  years,  10.5  per  cent  of  those  who  had  suffered  gonorrhea 
without  epididymitis  were  childless,  against  23.4  per  cent  of  those  who 
had  had  single  epididymitis  and  41.7  per  cent  of  those  who  had  had  both 
organs  inflamed. 

Non-gonococcic  epididymitis  shows  much  more  tendency  to  relapse 
and  doubtless  through  its  suppuration  results  more  frequently  in  steril- 
ity of  the  testicle  involved.  But  it  is  so  rarely  bilateral  that  the  patient 
does  not  realize  his  defect. 

On  the  other  hand,  traumatic  epididymitis  is  far  less  likely  than 
urethral  epididymitis  to  lead  to  sterility,  since  the  traumatic  inflamma- 
tion concerns  the  testicle  and  the  surrounding  tissue  rather  than  the 
lumen  of  the  canals.  Thus  Liegeois  ( Jacobson)  found  spermatozoa  in 
the  semen  of  only  7  out  of  28  patients  who  had  had  double  epididymitis, 
and  of  these,  5  cases  were  due  to  "local  causes."  Orchitis  does  not 
cause  sterility  unless  the  testicles  atrophy. 

TREATMENT  OF  EPIDIDYMITIS 

Prophylaxis. — The  prevention  of  epididymitis  during  the  treat- 
ment of  an  inflamed  urethra  is  compassed  by  means  of  gentleness.  It 
is  impossible  to  lay  down  a  fixed  rule  by  which  this  complication  may 

^ArcUv  f.  Derm.  u.  Syph.,  1898,  xlv,  33. 


EPIDIDYMITIS  573 

always  be  avoided.  Even  the  rough  passage  of  sounds  through  an  in- 
flamed urethra  does  not  always  cause  it,  while  it  may  be  excited  by  the 
gentlest  of  injections. 

It  is  evident  that  inflammation  invades  the  epididjonis  when  a  focus 
in  the  prostate  or  vesicle  is  lighted  up  by  the  trauma  of  urethral  treat- 
ment. Yet  the  presence  of  this  focus  cannot  always  be  ascertained, 
and,  inasmuch  as  the  complication  sometimes  arises  when  no  urethral 
treatment  is  being  employed,  one  cannot  but  feel  a  certain  fatality  in 
the  matter.  All  that  can  be  done  is  to  exercise  the  greatest  possible 
gentleness,  especially  in  the  introduction  of  dilating  and  metal  instru- 
ments. 

During  acute  gonorrhea  it  is  customary  to  instruct  the  patient  to 
wear  a  suspensory  bandage,  and  this  measure  certainly  reduces  the  dan- 
ger of  epididymitis,  though  it  does  not  entirely  prevent  it. 

Treatment  of  Gonorrheal  Epididymitis. — The  treatment  consists  of 
rest  in  bed,  elevation  of  the  testicle,  applications  to  the  testicle,  and 
general  medication. 

Rest  in  Bed. — ^Although  the  mildest  cases  do  not  always  require 
rest,  one  can  never  be  sure  when  the  first  symptom  of  epididymitis 
appears  whether  the  case  will  remain  mild  or  whether,  starting  mildly, 
it  will  not  go  on  by  progressive  extension  to  a  prolonged  or  acute  in- 
flammation. Whenever  this  is  possible,  rest  in  bed  is  therefore  re- 
quired. 

Elevation"  of  the  Testicle. — Proper  elevation  of  the  testicle 
constitutes  almost  the  sum  of  the  treatment  of  acute  epididymitis. 
Simple  as  this  statement  seems,  it  is  no  easy  matter  to  carry  it  into 
practice,  for  proper  elevation  of  the  testicle  is  very  hard  to  achieve. 
Relatively  good  elevation  may  be  achieved  by  a  gTeat  variety  of  devices, 
among  which  one  of  the  simplest  is  the  ordinary  jock-strap  or  suspensory 
bandage  supplemented  by  a  roll  of  gauze,  the  center  of  which  is  pinned 
underneath  the  testicle  while  its  ends  are  brought  around  each  groin, 
and  then  around  the  back,  and  tied  in  front  of  the  belly.  The  tightening 
and  loosening  of  this  bandage,  according  to  the  patient's  needs,  often 
supplies  excellent  support  especially  for  stout  people.  Adhesive  plaster 
I  do  not  care  for  during  the  acute  stages  of  the  disease. 

If  the  patient  is  thoroughly  under  control  in  a  hospital,  or  under 
the  care  of  a  nurse  who  understands  its  management,  the  bandage  de- 
vised by  the  late  Dr.  Samuel  Alexander  is  far  superior  to  any  I  know. 
For  four  years  I  have  employed  it  in  Belle\aie  Hospital  with  entire 
success  in  all  cases  where  the  vas  was  not  involved,  and  the  condition 
did  not  go  on  to  suppuration.  The  great  majority  of  gonorrheal  cases, 
in  other  words,  yielded  to  this  treatment  immediately.  On  succeeding 
Dr.  Alexander  I  found,  and  continued,  the  rule  that  no  matter  what 
the  patient's  condition  when  he  entered  the  ward,  his  temperature 


574       INFLAMMATIONS  OF  THE  TESTICLE  AND  EPIDIDYMIS 

should  drop  to  normal  within  forty-eight  hours  of  the  time  the  bandage 
was  applied ;  he  should  be  up  and  about  for  one  or  two  days  more  and 
home  on  the  fifth  day.  Any  patient  not  fulfilling  this  routine  either  has 
his  bandage  badly  applied,  or  a  deferentitis,  or  a  probability  of  suppura- 
tion. 

The  bandage  consists  of  two  parts :  ( 1 )  A  Canton  flannel  belt,  four 
inches  wide,  is  pinned  about  tKe  abdomen.  (2)  A  T-bandage  made  from 
the  ordinary  roll  of  gauze  about  three  feet  in  length  to  the  center  of 
which  is  sewn  the  ends  of  two  strips  of  Canton  flannel  about  four 
feet  long  each.  To  the  point  of  juncture  of  the  Canton  flannel  and 
the  roll  of  gauze  a  pad  of  gauze  is  pinned.  This  pad  is  usually  made 
two  inches  long,  one  inch  wide,  and  about  a  quarter  of  an  inch  thick, 
but  its  size  must  be  varied  in  different  cases.  After  the  Canton  flannel 
belt  has  been  snugly  pinned  about  the  patient's  middle,  the  T-bandage 
is  so  applied  that  the  pad  of  gauze  rests  immediately  beneath  the 
patient's  testicles,  the  two  Canton  flannel  streamers  extend  around  the 
gluteal  curve  and  are  pinned  to  the  sides  of  the  belt,  while  the  two  ends 
of  the  gauze  roll  are  brought  up  on  each  side  of  the  groin  encircling  the 
testicles  and  penis.  Their  lower  edges  are  overlapped  above  the  penis 
very  snugly  so  that  they  form  the  neck  of  a  sack  from  which  the  testi- 
cles cannot  slip  (thanks  to  the  little  pad)  no  matter  how  hard  the 
traction  upward  over  the  abdomen.  The  ends  of  the  gauze  roll  above 
this  pin  are  now  folded  over  each  other  to  make  a  broad,  flat  band  upon 
which  traction  is  made,  whereby  the  testicles  are  pulled  up  literally  onto 
the  pubes. 

If  the  bandage  is  properly  adjusted,  and  there  is  no  inflammation 
of  the  vas  deferens,  the  discomfort  caused  to  the  most  exquisitely  sensi- 
tive testicle  is  unimportant,  and  as  soon  as  the  bandage  has  been  pinned 
well  up  on  the  belly  band,  this  discomfort  disappears,  and  is  replaced  by 
a  sense  of  great  relief.  A  piece  of  gauze  is  then  loosely  pinned  across 
the  front  of  the  scrotum  in  order  that  when  the  patient  rolls  around  in- 
bed  his  testicles  may  not  slip  from  the  bandage.  But  great  care  must 
be  taken  to  pin  this  cloth  very  loosely  so  as  not  to  force  the  testicles  back, 
since  the  whole  object  of  the  bandage  is  to  force  them  forward. 

If  the  vas  deferens  is  already  involved,  even  though  it  be  only 
tender,  one  has  to  modify  the  bandage  to  the  extent  of  easing  up  on 
the  edge  of  that  side  so  as  not  to  press  too  tight  in  the  groin. 

If  the  patient  is  not  well  in  three  or  four  days  after  the  application 
of  this  bandage,  it  is  usually  wise  to  operate;  otherwise  the  inflamma- 
tion will  be  a  tedious  one,  very  possibly  complicated  by  suppuration, 
and  almost  certainly  by  considerable  inflammation  of  the  vas  deferens. 

The  patient  may  get  out  of  bed  twenty-four  hours  after  the  tempera- 
ture has  become  normal  if  the  attack  has  been  a  brief  one,  forty-eight 
hours  after  if  it  has  been  prolonged.     The  above-described  bandage 


EPIDIDYMITIS  575 

should  then  be  discarded  in  favor  of  a  jock-strap  or  an  adhesive  plaster 
dressing.  The  latter  consists  of  strips  of  plaster  some  two  inches  broad 
running  from  the  perineum  on  to  the  abdomen,  first  on  one  side 
and  then  on  the  other,  lifting  the  testicles  up  as  high  as  possible.  This, 
or  the  jock-strap,  should  be  worn  for  at  least  a  week.  Then  if  a  con- 
siderable degree  of  swelling  still  remains  in  the  epididymis  this  may 
be  reduced  by  strapping  as  described  below.  This  strapping  has  been 
dignified  by  the  title  of  "Beer's  compression." 

If  the  case  has  been  properly  treated  it  usually  subsides  so  quickly 
that  no  strapping  is  required  but  the  patient  discards  his  jock- 
strap for  an  ordinary  suspensory  which  he  wears  for  three  or  four 
weeks. 

Local  Applications. — Poultices  are  light  and  soothing;  there 
seems  to  be  no  particular  virtue  in  the  once-lauded  tobacco  poultice. 
Tucker's  saturated  solution  of  magnesium  sulphate  applied  on  several 
layers  of  gauze  and  covered  with  rubber  tissue  probably  acts  as  a  nega- 
tive poultice.  Guaiacol,  one  part,  in  glycerin,  ten  parts,  is  an  ad- 
mirable counterirritant  for  mild  chronic  epididymitis.  I  have  dis- 
carded guaiacol  in  the  treatment  of  acute  infections.  Hot  water  bags 
are  heavy.  To  most  patients  the  application  of  cold,  in  the  form  of 
an  ice  pack,  is  more  grateful  than  heat,  but  if  the  bandage  above  de- 
scribed is  properly  applied,  no  further  relief  of  pain  is  usually  re- 
quired. 

General  Treatment. — Apart  from  a  light  diet  and  rest  in  bed, 
specific  drugs,  such  as  aconite  and  vaccines,  have  fallen  into  merited 
disfavor. 

Operative  Treatment. — Hagner  justly  claims  for  his  operation 
the  immediate  relief  of  pain,  but  the  convalescence  from  the  operation 
requires  longer  than  that  from  the  use  of  the  bandage  described  above, 
and  we  reserve  operative  treatment  for  those  upon  whom  this  elevation 
fails. 

The  claim  that  operation  reduces  the  prospect  of  sterility  after 
epididymitis  is  not  supported  by  any  very  large  statistics  and  is,  per- 
haps, not  well  founded.  A  similar  claim  has  been  made  for  the  Beer 
treatment  by  compression  with  a  rubber  bandage. 

Strapping. — The  strapping  should  be  done  so  as  to  produce  the 
maximum  of  pressure  with  the  minimum  of  discomfort,  and  at  no  time 
should  the  testicle,  which  remains  tender,  be  squeezed  tightly  enough 
to  produce  any  lasting  uneasiness.  The  method  of  strapping  the  testicle 
which  I  now  employ  is  far  superior  to  the  old  way  with  overlying 
strips  of  adhesive  plaster.     It  was  devised  by  Dr.  Chetwood. 

A  piece  -of  tape  is  first  tied  rather  snugly  about  the  base  of  the 
scrotum  to  hold  the  inflamed  testicle  down  and  its  fellow  up  out  of 
the  way.    A  strip  of  light  rubber  (Martin)  bandage,  15  or  20  cm.  long 


576       INFLAMMATIONS  OF  THE  TESTICLE  AND  EPIDIDYMIS 


and  10  cm.  wide,  and  a  piece  of  adhesive  plaster,  1  cm.  wide  and  10 
cm.  long,  constitute  the  apparatus. 

The  adhesive  plaster  is  stuck  to  one  end  of  the  bandage  as  shown  in 
Fig.  121.  The  scrotum  is  gently  lifted  and  the  uninflamed  testicle 
pushed  up  out  of  the  way.  The  inflamed  organ  is  then  encircled  with 
the  rubber  bandage  as  tightly  as  the  patient  can  bear  it  (this  is  a  matter 
of  experience),  and  as  the  bandage  is  wrapped  in  place  the  adhesive 


Fig.     121. — Rubber 
Bandage    for 

Strapping. 


Fig.  122. — The  Bandage  Applied. 


plaster  is  brought  around,  and  holds  it  fast  (Fig.  122).  Absolutely 
the  only  precaution  necessary  is  to  get  the  line  of  greatest  pressure  above 
the  line  of  greatest  swelling — i.  e.,  to  make  the  adhesive  plaster  encircle 
the  organ  above  its  equator,  for  otherwise  it  will  promptly  slip  ott". 
The  advantages  of  this  bandage  need  not  be  enumerated,  but  the  chief 
one  is  that  it  may  be  removed  daily  to  be  put  on  more  tightly.  This  it 
is  expedient  to  do. 

The  Urethra. — Last,  but  not  least,  7io  local  treatment  to  the  ure- 
thra should  be  attempted  during  or  after  an  attack  of  epididymitis.  It 
will  only  harm  the  testicle  without  helping  the  canaL  The  lengih  of 
time  that  must  elapse  before  the  urethra  is  again  treated  locally  varies. 
For  most  patients  two  weeks  suffice. 

Recurrent  Epididymitis. — Each  attack  of  recurrent  epididymitis 
may  be  treated  by  the  measures  detailed  above ;  but  between  times  pre- 
ventive measures  must  be  instituted  to  ward  off  future  attacks.     This 


EPIDIDYMITIS  577 

prophylactic  treatment  may  be  directed  toward  the  general  health,  thr 
seminal  vesicle,  and  the  testicle  itself. 

A  strict  hygiene,  sexual  and  general,  is  essential  in  every  case. 
Aided  by  tonics,  milk,  fats,  etc.  (with  perhaps  a  vacation),  this  alone 
may  effect  a  cure. 

The  treatment  of  the  posterior  urethra  depends  upon  its  tolerance. 
If  it  will  bear  instrumentation,  instillations,  irrigations,  and  massage 
help;  but  in  a  certain  proportion  of  cases  such  attempts  only  serve  to 
stir  up  the  testicle  and  make  the  patient  worse.  The  hot  rectal  douche 
is  here  peculiarly  applicable,  since  it  is  absolutely  harmless. 

The  testicle  itself  should  always  be  supported.  I  have  known  a  man 
who  could  not  for  three  months  leave  off  a  towel  T-bandage  which  slung 
his  testicles  over  his  abdomen.  No  lesser  support  would  prevent  a  re- 
currence of  the  attacks.    Yet  he  is  now  permanently  well. 

If  all  these  palliative  measures  fail,  there  is  but  one  alternative. 
The  patient  must  either  get  along  with  his  testicle  as  well  as  he  may, 
or  submit  to  vasotomy  with  puncture  and  drainage  of  the  focus  in  the 
epididymis.  I  hesitate  to  advocate  this  operation.  But,  on  the  other 
hand,  in  every  case  put  to  the  test,  the  effect  has  been  immediate,  abso- 
lute, and  permanent.  ISTot  one  died,  not  one  relapsed,  not  one  but  was 
intensely  gratified  with  the  operation.  I  have  watched  one  case  for 
four  years,  others  for  a  less  time.  This,  at  least,  can  be  said  of  it :  that 
the  operation  itself  is  quite  insignificant,  and  that,  like  epididymitis,  it 
never  causes  impotence,  loss  of  desire,  or  atrophy  of  the  testicle. 

ORCHITIS 

Secondary  orchitis — orchitis  complicating  epididymitis — is  very 
rare.  Primary  orchitis — orchitis  due  to  traumatism  or  to  systemic  dis- 
ease— is  also  rare.  Exceptionally  orchitis  occurs  without  discoverable 
cause. 

VARIETIES 

Several  types  of  orchitis  may  be  distinguished : 

1.  Traumatic  orchitis. 

2.  Metastatic  orchitis.  We  are  chiefly  concerned  with  this  form  of 
the  disease.  It  is  a  common  complication  of  mumps,  and  has  occa- 
sionally been  met  with  during  typhoid  fever,^  influenza,  small-pox,  ton- 
sillitis, and  rheumatism."    The  orchitis  of  mumps  is  a  type  of  these. 

Traumatic  Orchitis. — Severe  contusion,  commonly  a  kick  or  a  blow 
inflicted  by  a  missile,  causes  an  acute  inflammation  of  the  testis  and 
epididymis,  -  which,    though    usually    short-lived,    may    terminate    in 

*Cf.  Kinnicutt,  Med.  Record,  1901,  lix,  801. 
'Guyon's  Annalcs,  1894,  xii,  306. 


578       INFLAMMATIONS  OF  THE  TESTICLE  AND  EPIDIDYMIS 

atrophy  of  the  testis,  abscess,  or  gangrene.  Lesser  bruises  or  strains 
cause  an  inflammation  which  habitually  terminates  in  resolution  only. 
Yet  atrophy  may  follow  a  slight  injury. 

Orchitis  from  strain  has  been  attributed  to  spasm  of  the  cremaster 
and  to  compression  of  the  cord  by  the  abdominal  muscles  ( Velpeau) .  It 
may  perhaps  be  due  to  slight  torsion. 

Orchitis  of  Mumps. — The  orchitis  of  mumps  is  most  frequent  at 
about  puberty.  It  is  almost  unknown  in  childhood.  It  comes  on  near 
the  end  of  the  first  week  of  mumps,  and  is  usually  confined  to  a  single 
testicle.  The  testicle  may,  however,  become  inflamed  before  the  parotid, 
and  the  mumps  may  even  be  confined  to  the  testicle.  Orchitis  occurs  in 
at  least  5  per  cent  of  cases  of  mumps  in  young  adults.  Indeed,  Laveran^ 
met  with  156  cases  of  orchitis  among  432  cases  of  mumps  occurring  in 
soldiers.  The  epididymis  may  or  may  not  be  involved.  The  affection 
runs  a  quick  course  of  about  a  week  or  ten  days,  very  rarely  terminates 
in  suppuration,  may  subside  without  leaving  behind  any  impairment  of 
the  organ,  but  is  often  followed  by  atrophy.  This  occurred  in  73  of 
Laveran's  cases.    Abscess  and  gangTene  are  very  rare. 

SYMPTOMS 

Local  Symptoms.^The  testis  increases  slowly  in  size,  and  seldom 
becomes  very  large.  This  is  due  to  the  unyielding  nature  of  the  al- 
buginea,  and  to  the  fact  that  there  is  usually  no  effusion  into  the  tunica 
vaginalis.  The  pain,  which  is  often  excruciating,  and  always  out  of 
proportion  to  the  amount  of  swelling,  is  due  to  the  tension  of  the  al- 
buginea.  This  pain  has  been  compared  to  that  of  nephritic  or  hepatic 
colic.  iSTo  position  gives  rest,  and  any  handling  of  the  organ  may 
induce  syncope.  The  pain  continues  severe  for  several  days,  and  then 
gradually  becomes  more  bearable,  or  it  may  suddenly  cease  altogether. 
This  last  circumstance  is  gTatifying  to  the  patient  only,  for  it  may  mean 
gangrene  of  the  organ. 

The  shape  of  the  testicle  is  rarely  altered  in  orchitis ;  it  is  smoothly, 
regularly  ovoid.  The  epididymis  is  not  distinguishable  from  the  rest 
of  the  tumor.  The  scrotal  tissues  are  often  red,  swollen,  edematous, 
inflamed. 

General  Symptoms. — The  general  symptoms  in  true  orchitis  are 
marked,  often  severe :  chills,  high  fever,  vomiting,  hiccough,  sleepless- 
ness, etc.  These  symptoms  have  been  compared  to  those  of  strangulated 
hernia.  Indeed,  there  is  more  or  less  strangulation  of  the  testicle 
within  its  tight,  fibrous  sheath. 

Termination. — The  disease  usually  terminates  by  resolution.  The 
testicle  may  then  remain  normal  or  it  may  go  on  to  atrophy,  this  process 

»  Med.  Times  and  Gazette,  vi,  July  20,  1878. 


TREATMENT  579 

requiring  several  weeks,  at  the  end  of  which  time  nothing  is  left  of  the 
testicle  but  a  small,  insensitive  mass.  Abscess  is  a  rare  termination  and 
gangrene  still  more  rare. 

TREATMENT 

Treatment. — It  is  stated  that  the  orchitis  of  mumps  does  not  occur 
if  the  patient  is  kept  in  bed  for  eight  days.  Such  a  precaution  is  there- 
fore a  wise  one  for  all  voung  adults,  though  they  cannot  always  be  made 
to  comply  with  it.     The  testicles  should  also  be  kept  supported. 

After  the  attack  has  once  begun  the  patient  needs  no  urging  to  keep 
him  in  bed.  Ice  may  relieve  pain.  If  the  symptoms  fail  to  abate  it  is  w^  ise 
to  resort  without  delay  to  subcutaneous  section  of  the  tunica  albuginea 
in  order  to  take  off  tension  from  the  strangulated  parts  within.  This 
simple  operation  is  readily  performed  with  a  sharp  tenotomy  knife  in- 
troduced through  the  skin,  and  then  made  to  cut  the  tense  fibrous  cap- 
sule, while  the  testicle  is  steadied  in  the  other  hand.  The  incision 
should  be  carried  fairly  through  the  tunica  albuginea,  three  to  six 
short  cuts  5  to  10  cm.  long  being  made  at  different  points  on  the  surface 
of  the  testicle.  The  pain  will  usually  cease  after  the  tension  has  been 
relieved.     Abscess  requires  drainage,  gangrene  castration. 

Fistulae  are  treated  secundum  artem;  drained,  curetted,  and 
cupped.  A  thoroughly  disorganized  fistulous  testicle  had  best  be  re- 
moved. 


CHAPTER   LX 

TUBERCULOSIS  OF  THE  EPIDIDYMIS 

TiJBEECiJLOSis  affects  the  testicle  in  two  ways : 

1.  Diffuse  miliary  tuberculosis,  associated  with  general  miliary 
tuberculosis,  and  of  no  interest  to  the  surgeon. 

2.  Circumscribed  tuberculosis,  which  concerns  us  here.  This  form 
of  tubercle  appears  as  localized  deposits,  one  or  more,  beginning  in  the 
epididymis,  and  involving  the  testicle  only  secondarily. 

ETIOLOGY 

Pathogenesis — There  are  three  theories  concerning  the  genesis  of 
genital  tuberculosis : 

1.  That  it  is  primary  in  the  prostate  or  the  seminal  vesicles  whence 
the  epididymis  is  invaded  secondarily,  the  inflammation  extending  along 
the  vas,  or,  possibly,  by  way  of  the  lymphatics  (Kocher,^  Lanceraux,^ 
Guyon,^  Simmonds,^  Walker^). 

2.  That  genital  tuberculosis  is  primary  in  the  epididymis,  secondary 
in  the  prostate  and  seminal  vesicles  (Reclus,''  Senn,'''  Councilman,^ 
Barney  ^ ) . 

3.  That  the  tuberculosis,  whether  occurring  primarily  in  the  one 
end  of  the  seminal  canals  or  in  the  other,  may  be  due  to  inoculation  dur- 
ing coitus  (Verneuil,  Jacobson,^°  Paladino-Blandini  ^^). 

Two  questions,  therefore,  arise :  Can  the  inoculation  take  place  dur- 
ing coitus  ?     Is  the  epididymis  invaded  primarily  or  secondarily  ? 

As  to  infection  during  coitus,  no  one  holds  that  such  infection  is  at 

^  Op.  cit.,  p.  326. 

^  Guyon's  Annales,   188.3,   i,  153. 

Uhid.,  1891,  ix,  445. 

*Beitr.  z.  Uin.  d.  The,  Nov.,  1914,  No.  1. 

^Lancet,   1913,  clxxxiv,  435. 

»"Du  tubercule  du  testicule,"  Paris,  1876. 

'"Tuberculosis  of  the  Gen.-Urin.  Organs,"  1897,  p.  48. 

•Dennis's  "Surgery,"  1895,  i,  246. 

"  Bost.  Med.  and  Surg.  Jour.,  July  3,  1913. 

^^  Op.  cit.,  p.  323. 

^^Guyon's  Annales,  1900,  xviii,  1009. 

580 


ETIOLOGY  581 

all  frequent.  The  question  is  whether  or  not  it  ever  occurs.  Tubercle 
bacilli  have  been  found  in  the  healthy  epididymis  (Jani  and  Weigert  ^), 
and  Paladino-Blandini  and  T.  Walker  have  apparently  shown  that 
bacteria,  tubercle  bacilli  among  others,  when  deposited  on  the  mucous 
membrane  of  the  urethra  near  the  meatus  may  reach  the  epididymis, 
but  cause  no  inflammation  there  under  ordinary  conditions.  Yet  these 
experiments  prove  only  that  infection  in  coitus  is  barely  possible,  for 
the  combination  of  circumstances  postulated — viz.,  a  massive  urethral 
inoculation  and  a  trauma  to  the  testicle' — would  be,  clinically,  hard  to 
find.     Inoculation  per  urethram  is,  to  say  the  least,  improbable. 

Is  the  epididymis  invaded  primarily  or  secondarily  ?  The  highest 
authorities  are  divided  on  this  point,  and  perhaps  this  division  is 
founded  on  a  diversity  of  cases,  some  primary,  some  secondary.  There 
is  no  question  here  of  the  primai-y  focus  in  the  body,  but  only  of  the 
primary  focus  in  the  genital  tract.  Is  it  in  the  epididymis,  or  is  it  in  the 
prostate  and  vesicle  ?  I  cannot  answer  the  question  except  by  an  array 
of  facts,  all  of  which  seem  to  point  toward  the  same  conclusion:  (1) 
I  have  examined  the  urine  of  every  case  of  tuberculous  epididymis  that 
I  have  seen  in  the  last  ten  years,  and  in  no  case  have  I  failed  to  find  in 
the  urine  either  shreds  or  pus  (indicative  of  a  prostatic  congestion). 
(2)  I  have  seen  tuberculous  prostatitis  and  vesiculitis  without  any 
lesion  of  the  epididymis.  (3)  When,  one  epididymis  being  already 
involved,  the  other  one  becomes  implicated,  I  am  confident  that  tuber- 
culous internal  genitals  form  the  bridge  from  one  side  to  the  other, 
and  therefore  the  second  epididymis,  at  least,  is  not  involved  primarily. 

To  sum  up :  With  a  tuberculous  epididymis  the  prostate  is  never 
normal  (though  its  congestion  may  possibly  be  similar  to  that  seen  about 
the  mouth  of  the  ureter  in  a  tuberculous  kidney)  and  is  sometimes  mani- 
festly tuberculous  to  rectal  touch.  On  the  other  hand,  with  a  tuberculous 
prostate  or  vesicle  the  epididymis  is  not  necessarily  involved.  Involve- 
ment of  the  prostate  precedes  involvement  of  the  second  testicle.  The 
migration  of  the  bacteria  in  sufficient  numbers  to  cause  damage  is  ren- 
dered intelligible  by  Paladino-Blandini's  experiments,  referred  to  above, 
which,  while  they  do  not  reproduce  the  conditions  requisite  for  infec- 
tion in  coitus,  do  represent  with  sufficient  accuracy  the  conditions  of 
so-called  ascending  inflammation.  All  the  weight  of  this  evidence  goes 
to  show  that,  in  many,  if  not  in  all,  cases,  the  prostate  or  vesicle  is 
tuberculous  before  the  epididymis  becomes  so.  T.  Walker  believes  that 
the  urine  from  a  tuberculous  kidney  usually  is  the  source  of  the  primal 
prostatic  focus. 

The  supporters  of  the  theory  of  primary  epididymal  tuberculosis 
insist  upon  the  fact  that  biologically  the  epididymis  is  an  excretory 
organ  infected  like  the  kidney  from  the  blood  stream. 

^Virchow's  ArcMv,  1886,  ciii,  522. 


582  TUBERCULOSIS  OF  THE  EPIDIDYMIS 

The  age  at  which  tuberculous  inflammation  is  most  common  is  be- 
tween twenty  and  thirty.  Fully  half  the  cases  occur  between  these 
years,  and  the  disease  is  very  rare  before  fifteen  and  after  fifty.  But  a 
number  of  cases  have  been  reported  in  infancy.^ 


PATHOLOGY 

Authorities  diifer  as  to  whether  the  epithelium  or  the  intertubular 
tissues  of  the  ejndidymis  are  first  involved,  and  on  these  differences 
build  a  support  to  their  views  upon  the  primary  and  secondary  nature 
of  the  disease.      The  first  lesion  is  almost   invariably  found  in  the 


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Fig.  123. — Specimens  Obtained  by  Orchidectomy  and  Epididymectomy  for  Tubercu- 
losis. The  epididymes  (laterally)  are  tuberculous  throughout;  on  right  side  was  much 
enlarged;  on  left  normal.     Testis  (center)  split,  showing  tubercles. 

globus  minor  of  the  epididymis.  There  it  may  remain  localized,  or 
it  may  spread  by  continuity  throughout  the  epididymis  and  the  testicle, 
or  distinct  foci  may  appear  in  the  head  of  the  epididymis.  The 
tubercles  conglomerate  to  form  the  hard  masses  so  typical  of 
tuberculosis.  These  go  on  usually  to  caseation,  suppuration,  and  fistuli- 
zation,  or  else  cicatrize  or  calcify. 

The  Vas. — The  vas  is  often  lumpy  with  tuberculous  deposits,  and 
may  be  involved  in  a  perideferentitis  throughout  its  length.  The  vesicle 
and  prostate  may  be  clinically  tuberculous. 

The  Testicle.— The  testicle  is  often  invaded  by  a  tuberculoma  or 
by  an  abscess.  Primary  tuberculosis  of  this  organ  does  not  occur. 
Yet  testes  obtained  by  castration  often  show  a  more  or  less  widely  dis- 

*  Cf .  Viguard  and  Thevowot,  Ann.  de  med.  et  chir.  inf.,  1911,  xv,  561.  Also 
Lyons,  Jour.  A.  M.  A.,  1913,  Ixi,  2051, 


PATHOLOGY 


583 


seminated  beginning  tuberculosis  of  this  gland.  This  discovery  has 
been  hailed  as  startling  proof  of  the  advantage  of  total  castration;  it 
being  very  justly  urged  that  the  lesions  in  the  testicles  would  be  over- 
looked by  the  surgeon  intent  upon  epididymectomy.  It  is  true  that 
these  lesions   of  the  testicles   are   often  present   in   cases  treated  by 


Fig.  124.^ — Section  of  Tuberculous  Testicle.     A  group  of  tubercles  invading  the  healthy- 
tissue. 

conservative  operations,  as  well  as  in  those  not  treated  surgically. 
But  the  testicle  is  able  to  overcome  the  infection  if  given  an  oppor- 
tunity by  epididymectomy.  Thus  Barney  ^  states  that  though  the 
testicle  is  clinically  tuberculous  in  44  per  cent  of  cases,  there  has  been 
no  local  relapse  after  epididymectomy  in  "almost  100  cases." 

The  Vaginalis.— The  tunica  vaginalis  may  be  studded  with  tubercles, 
producing  chronic  hydrocele.  Operation  always  reveals  hydrocele  or 
adhesions  within  the  vaciualis. 


^Boston  Med.  and  Surg.  Jour.,  1913,  clxviii,  No.  25. 


584  TUBERCULOSIS  OF  THE  EPIDIDYMIS 

The  Urinary  Organs. — The  urinary  organs  are  often  affected  with 
the  genital  organs  in  at  least  one-third  of  all  cases. 

The  Lungs — The  lungs  are  often  enough  spared.  Thus  Kocher, 
among  451  autopsies  on  cases  of  urogenital  tuberculosis,  found  as  manj 
as  95  (21  per  cent)  with  normal  lungs.  During  life  the  pulmonary  in- 
volvement is  often  insignificant.  On  the  other  hand,  Reclus  found, 
among  500  phthisical  patients,  64  with  genito-urinary  tuberculosis,  45 
with  involvement  of  the  genital  tract,  and  19  with  tuberculous  testes 
only. 

SYMPTOMS 

The  patient,  a  young  man,^  comes  complaining  that  one  testicle  is 
larger  than  the  other.  The  swelling  may  have  been  spontaneous  or 
it  may  have  followed  injury,  or  perhaps  a  previous  gonorrheal  epididy- 
mitis never  got  entirely  well  and  began  to  swell  again.  Question- 
ing may  disclose  a  family  or  a  personal  history  of  tuberculosis,  or  an 
account  of  frequent  and  painful  urination  perhaps  slight,  previous,  or 
still  existing.  The  epididymal  lesion  is  almost  always  tender,  rarely 
painful. 

Less  often  the  onset  is  acute.  The  testicle  is  greatly  swollen  and 
hard.  There  is  considerable  pain,  and  the  vaginalis  rapidly  fills.  This 
condition  may  subside,  leaving  a  few  nodules  here  and  there,  or  it  may 
go  on  to  suppuration. 

Upon  examining  such  a  testicle  it  is  usually  found  somewhat  en- 
larged throughout,  with  large,  hard  nodules  at  one  end  or  the  other  of 
the  epididymis,  or  throughout  its  length.  There  may  be  lumps  in  the 
testicle  itself.  The  outline  may  be  obscured  by  fluid  in  the  tunica 
vaginalis.  The  vas  deferens  may  be  knotty,  enlarged,  and  hard,  as  far 
as  it  can  be  felt,  and  a  finger  in  the  rectum  may  detect  the  seminal 
vesicle  similarly  affected.  Nodules  may  perhaps  also  be  detected  in 
the  prostate;  the  urine  contains  shreds  or  free  pus,  and  there  are,  per- 
haps, symptoms  referable  to  tuberculosis  of  prostate,  bladder,  or  kidney. 
The  lungs,  too,  may  be  involved.  Sexual  power  and  desire  are  in- 
fluenced only  by  the  fears  of  the  patient. 

COURSE 

The  malady  usually  advances  slowly,  sometimes  remaining  station- 
ary for  many  mouths.     Finally,  the  nodules  soften,  the  skin  adheres, 

*  Goodman  (Med.  Bee,  1914,  Ixxxv,  146)  has  collected  91  cases  of  tuberculosis 
of  the  testicle  in  children,  half  of  them  appearing  in  children  less  than  two  years 
old.  The  lesion  usually  suppurates  and  involves  both  the  testicle  and  the  epididymis. 
It  therefore  requires  orchidectomy. 


COURSE  585 

bursts  and  discharges  a  thick,  cheesy  material.  The  fistula  persists  in- 
definitely.    But  after  many  months  it  usually  heals. 

We  occasionally  meet  with  a  case  which  starts  like  an  ordinary 
acute  epididymitis,  the  tuherculose  galopante  du  testicule  of  Duplay, 
and  never  remits  its  fury.  In  other  cases  the  chronic  course  of  the 
disease  is  interrupted  by  acute  exacerbations. 

The  cases  ^  may  be  divided  into  two  classes:  (1)  those  in  which  the 
epididymal  lesion  is  the  chief  active  tuberculous  lesion  in  the  body  (26 
cases),  and  (2)  those  in  which  the  tuberculous  lesion  is  only  a  part — 
perhaps  a  relatively  unimportant  part — of  genito-urinary  (24  cases)  or 
general  (31  cases)  tuberculosis;  but  no  patient  remains  hard  and  fast 
in  either  class.  The  clinical  picture  varies  as  one  or  another  lesion  rises 
into  prominence.  One  may  follow  clinically,  however,  and  with  some 
degree  of  order,  the  course  of  the  lesion  in  the  epididymis  itself  (where 
it  may  be  acute  or  chronic,  suppurating  or  quiescent)  and  in  its  fellow. 

The  acute  onset,  as  well  as  the  acute  exacerbations  during  the 
course  of  the  disease,  are  probably  due  to  mixed  infection.  Caseation 
and  fistula,  however,  occur  without  any  mixed  infection. 

Such  breaking  down,  whether  acute  or  chronic,  simple  or  tuber- 
culous, occurred  in  at  least  76  of  the  152  testicles  (probably  in 
more).  It  is  a  striking  fact,  however,  that  of  these  76  cases  of  soft- 
ening or  suppuration,  53  occurred  in  the  first  year,  while  late  sup- 
puration was  noted  only  once  in  the  third,  fourth,  and  fifth  years  re- 
spectively. 

It  would  seem,  therefore,  that  if  the  process  remains  chronic  in  the 
epididymis  for  a  year  or  two,   it  is  not  very  likely  to  break  down. 

On  the  other  hand,  no  suppuration  occurred  in  29  cases  watched  for 
more  than  one  year.  Fourteen  of  these  were  followed  less  than  four 
years,  9  from  four  to  nine  years,  and  6  respectively  ten,  eleven  (2 
cases),  twelve   (2  cases),  and  sixteen  years. 

Azoospermia.— I  have  observed  that  a  large  proportion  of  these 
patients  are  sterile  from  the  time  the  first  testicle  is  involved.  Barney 
states  that  85  per  cent  of  his  patients  were  sterile.  On  the  other  hand, 
Fiirbringer  -  alleges  that  tuberculosis  of  the  epididymis  is  less  likely  to 
entail  sterility  than  is  gonorrhea. 

Condition  of  the  Opposite  Testicle — Here  is  perhaps  the  most  im- 
portant point  of  all.  Many  patients  permit  one  testicle  to  be  removed 
in  the  hope  that  the  disease  is  confined  to  this  one  organ,  and  may  be 
amputated.  This  hope  is  utterly  vain,  and  relapse  upon  the  opposite 
side  frequently  occurs,  be  the  operation  ever  so  slight  or  ever  so  radical. 

This  is  proven  by  the  summary  of  my  87  cases  in  which  it  is  defi- 

*  This  and'  some  of  the  following  paragraphs  arc  quoted  from   my  report  of  a 
hundred  cases  of  tuberculous  epididymitis  in  the  Annals  of  Surgery,  June,  1907. 
'Deutsche  med.  Wochenschr.,  1913,  xxxix,  1393. 


586  TUBERCULOSIS  OF  THE  EPIDIDYMIS 

nitely  recorded  that  the  opposite  epididymis  was  or  was  not  affected. 
Fifty-three  so  relapsed;  34  had  not  done  so  when  last  seen. 

Involvement  of  the  opposite  epididymis  occurred  within  the  first  two 
years  in  46  cases.  In  only  3  did  this  occur  after  the  third  year,  though 
10  others  remained  unilateral  for  longer  periods, 

I  have  followed  69  cases  for  more  than  a  year.  Of  the  suppurating 
cases,  18  were  still  active  when  last  seen.  Sixteen  either  burst  or  were 
incised,  suppurating  for  a  certain  number  of  months  thereafter,  and 
then  were  seemingly  cured.  Seven  such  apparent  cures  were  followed 
from  3  to  10  years;  1  for  12  (bilateral)  ;  1  for  13^ ;  1  for  25  (bilateral)  ; 
1  for  27  years.  Yet,  to  prove  that,  no  matter  how  long  these  patients 
remain  well  they  are  not  absolutely  guaranteed  against  relapse:  in 
one  case  suppuration  followed  gonorrhea  14  years  after  the  apparent 
healing. 

Thus  15  per  cent  of  cures,  watched  for  more  than  three  years  fol- 
lowed suppuration.  Yet,  on  the  other  hand,  those  cases  which  did  not 
suppurate  were  forever  smoldering  or  advancing.  Single  cases  showed 
irregular  activity  as  late  as  five,  six,  eight,  and  ten  years  after  the  onset ; 
while  apparent  cures  were  observed  at  five,  eight,  nine,  twelve,^  and 
sixteen  years — 14  per  cent. 

Mortality. — I  can  record  no  mortality  from  tuberculous  testicle.  One 
patient  died  of  phthisis,  2  of  tuberculous  meningitis,  and  2  of  pelvic 
abscess  after  operation ;  but  none  of  these  deaths  is  directly  attributable 
to  the  testicle. 

Barney  reports  that  41  per  cen^  of  58  patients  died  within  six 
years;  half  of  them  within  a  year  of  operation.  Miliary,  renal  and 
lung  tuberculosis  were  the  usual  fatal  agencies. 


DIAGNOSIS 

The  three  conditions  with  which  the  tuberculous  testicle  is  likely  to 
be  confused  are  simple  epididymitis,  syphilis,  and  neoplasm.  The 
means  for  distinguishing  the  three  are  the  following: 

1.  Aspiration  of  hydrocele  or  drainage  of  abscess  in  order  that  the 
lesions  of  testicle  and  epididymis  may  be  accurately  palpated. 

2.  Familiarity  with  the  clinical  aspect  of  tuberculosis  of  the  testicle 
— ^the  little  round  nodules ;  the  diffuse  infiltration  of  the  epididymis ; 
the  acute  epididymo-orchitis;  the  frequency  of  hydrocele  and  abscess; 
the  ever-present  sensitiveness  to  pressure. 

3.  Tuberculous  family  history  and  personal  history. 

4.  Evidence  of  tuberculosis  in  the  internal  genital  organs,  such  as 
active  lesions  or  chronic  tuberculous  nodules. 

*  Opposite  epididymes  of  one  patient. 


TREATMENT  587 

5.  The  diagnosis  can  be  proven  only  by  discovery  of  the  tubercle 
bacillus  in  the  urine,  in  the  pus  massaged  from  prostate,  or  in  the  con- 
tents of  hydrocele  fluid  or  abscess. 

Early  cases  are  especially  obscure.  If  the  lesion  is  in  the  epididymis 
and  sensitive,  it  is  not  syphilis ;  it  may  be  tuberculosis  or  simple  epidid- 
ymitis. In  the  absence  of  prostatic  tuberculosis  the  diagnosis  must 
be  reserved  for  a  few  weeks.  If  the  lesion  is  not  tuberculous  it  will 
quite  promptly  suppurate  or  resolve. 


TREATMENT 

Hygienic  Treatment. — The  hygienic  treatment  of  tuberculosis  is  the 
foundation  of  every  cure. 

Tuberculin  Treatment. — As  for  renal  tuberculosis. 

Surgical  Treatment. — It  is  bad  surgical  judgment  not  to  remove 
the  tuberculous  epididymis  unless  other  lesions  greatly  predominate  or 
prohibit  operation. 

Epididymectomy  removes  only  a  small  focus  of  tuberculosis ;  but 
it  has  the  incalculable  advantage  of  minimizing  the  lesions  of  prostate 
and  vesicles  that  are  not  accessible  to  direct  operation. 

Vasectomy  should  be  performed  on  the  unaffected  side  if  the  semen 
contains  no  spermatozoa. 

The  testicle  should  be  excised  only  when  it  is  gravely  diseased. 

If  radical  operation  is  contra-indicated  drainage,  curettage  and  cup- 
ping of  the  epididymal  lesion  are  called  for  unless  the  lesion  is  both 
small  and  quiescent. 


CHAPTER  LXI 
DISEASES   OF   THE  TESTICLE 

LUXATION  OF  THE  TESTICLE 

P.  Beuns  ^  records  the  case  of  a  man  run  over  while  lying  on  his 
back.  The  right  testicle  was  dislocated  over  the  pubis  at  the  root  of  the 
penis.  It  remained  there  and  did  not  atrophy.  He  refers  to  other  trau- 
matic dislocations,  one  under  the  skin  of  the  thigh  and  a  number  into 
the  inguinal  canal. 

HYPERTROPHY  AND  ATROPHY 

Arrest  of  development  is  typical  in  the  retained  testis  and  may  also 
affect  the  normally  situated  organ  for  no  assignable  cause. 

True  atrophy  is  caused  by  orchitis,  by  pressure  (hydrocele,  elephan- 
tiasis), by  section  or  obstruction  of  the  spermatic  artery,  by  torsion,  by 
trauma,  by  severe  varicocele,  and  by  injuries  to  the  nerves,  spinal  cord, 
and  brain.  Sexual  excess  is  alleged  to  have  caused  atrophy  of  the 
testicles.  The  physiological  atrophy  of  old  age  has  been  studied  by 
Desnos,^  Griffith,^  and  Pawloff.* 

There  are  two  forms  of  atrophy,  the  one  sclerotic,  the  result  of  in- 
flammation, the  other  fatty,  the  result  of  an  obstruction  to  the  circu- 
,  lation. 

The  orchitis  of  mumps  is  the  most  frequent  cause  of  atrophy  of  the 
testicle. 

For  atrophy  of  the  testicle  there  is  no  treatment. 

CONTUSIONS  OF  THE  TESTICLE 

Severe  contusion  of  the  testicle  is  rare,  notwithstanding  its  exposed 
position.     There  is  ecchymosis,  and  perhaps  hematocele  or  orchitis; 

^  Mittheilungen  mis  der  chir.  Klinilc  zu  Tiibingcn,  1884,  iii,  483. 

'Guycn's  Annales,  1886,  iv,  72. 

Vow.  of  Anat.  and  Phys.,  1893-94,  xxviii,  209. 

*Guyon's  Annales,  1894,  xii,  291. 

588 


GANGRENE  OF  THE  TESTICLE  5S9 

atrophy  may  result.  One  of  tlie  modes  formerly  adopted  in  the  East 
for  emasculating  the  attendants  of  the  harem  was  that  of  squeezing 
the  testis.  The  inflammation  after  injury  may  be  sufficiently  severe  to 
result  in  abscess  or  gangrene. 

Kocher  records  2  deaths  from  the  shock  of  contusion  of  the  testicles. 

Treatment. — If  the  contusion  be  severe,  the  patient  must  be  placed 
at  once  upon  his  back,  with  the  testicle  elevated  and  covered  with  an  ice- 
cap;  if  subsequent  inflammation  occur,  it  must  be  met  appropriately 
(p.  579). 

WOUNDS  OF  THE  TESTICLE 

Punctured  wounds,  if  small,  are  of  no  importance.  Penetrating 
wounds  of  fair  size,  however,  permit  some  of  the  tubular  structure  of 
the  testis  to  escape.  This  is  likely  to  be  mistaken  for  a  slough,  and 
to  be  pulled  out  as  such.  Malgaigne  mentions  a  case  where  the  whole 
pulp  of  the  organ  was  pulled  out  in  this  way.  Injuries  to  the  testicle, 
whether  contusions  or  wounds,  are  exquisitely  painful,  and  give  rise 
to  faintness,  nausea,  vomiting,  and  even  convulsions.  The  testis  may 
atrophy  as  the  result  of  the  injury  or  of  a  subsequent  orchitis. 

Treatment. — ^Hernia  of  the  secreting  substance  should  be  reduced 
if  possible,  and  retained  by  pressure,  or  by  a  suture  through  the  tunica 
albuginea.  If  it  cannot  be  reduced,  it  may  be  snipped  off  with  the  scis- 
sors, but  should  in  no  case  be  pulled  upon. 


GANGRENE  OF  THE  TESTICLE 

Torsion  of  the  Spermatic  Cord — Gangrene  of  the  testicle  is  com- 
monly due  to  this  cause.  Scudder  ^  has  collected  31  cases,  to  which 
he  adds  1  of  his  own.  Of  the  32  cases,  17  occurred  on  the  right  side,  11 
on  the  left.  Seventy-five  per  cent  occurred  in  patients  under  twenty- 
three,  at  an  age,  namely,  when  the  individual  is  most  exposed  to  trau- 
matism, and  yet  the  trouble  was  usually  attributed  to  nothing  more 
violent  than  some  indefinite  strain.  Indeed,  in  several  cases  the  at- 
tacks were  recurrent ;  thus,  Van  der  Poel's  patient  learned  that  un- 
twisting the  testicle  relieved  the  pain. 

Etiology. — The  only  evident  predisposing  cause  is  malposition  of 
the  testicle.  Ten  times  the  aft'ected  gland  was  retained  in  the  ingaiinal 
canal,  5  times  close  under  the  pubes.  Hence  it  is  inferred  that  a  long 
mesorchium  is  required  to  permit  torsion  of  the  testis. 

Pathology. — The   pathological   changes    in   the   testicle   are  well 

^Annals  of  Surgery,  1901,  xxxiv,  234.  Loefberg  {Eygica,  1911,  Ixxiii,  No.  9) 
has  collected  79  cases. 


590  DISEASES  OF  THE  TESTICLE 

known  from  the  results  of  castration.  The  testicle  is  found  congested, 
hemorrhagic,  edematous,  or  gangrenous.  There  is  usually  vaginal 
hydrocele  or  hematocele.  The  cord  is  found  twisted  upon  itself  (out- 
ward in  7  cases,  inward  in  5)  one-half  to  two  and  one-haK  turns,  and 
strangulated  at  the  point  of  torsion. 

Ombredanne  ^  attributes  abscesses  of  the  testicle  in  lads  of  from 
10  to  15  to  torsion.  Among  seven  cases  operated  upon  this  condition 
was  certainly  present  in  four,  probably  in  six. 

Symptoms. — The  symptoms  are  usually  those  of  strangulated  her- 
nia. The  groin  and  scrotum  swell  rapidly  and  become  exquisitely 
sensitive.  The  patient  vomits  and  is  feverish  and  faint.  Chill  and  syn- 
cope may  occur.  If  the  testicle  is  normally  situated  it  may  unroll 
spontaneously,  thus  relieving  all  the  symptoms;  this  rarely  happens. 

It  is  probable  that  certain  cases  of  acute  spontaneous  orchitis  are 
due  to  slight  or  temporary  torsion  of  the  cord  (Ombredanne). 

Diagnosis. — Torsion  of  the  cord  has  been  distingTiished  from 
strangulated  hernia  by  the  mildness  of  the  systemic  disturbance,  after 
the  first  shock  has  passed,  in  contrast  with  the  severity  of  the  local 
symptoms.     In  case  of  doubt  immediate  operation  solves  the  difficulty. 

Treatment. — Recurrent  torsion  might  be  prevented  by  anchoring 
the  testicle  to  the  dartos. 

In  the  emergency  of  an  acute  attack  it  may  be  possible  to  untwist 
the  testicle,  as  was  done  by  IS'ash  an  hour  and  a  half  after  the  onset  of 
symptoms.  (The  testicle  subsequently  atrophied.)  In  the  majority 
of  cases,  however,  operation  affords  the  only  hope  of  relief.  The  opera- 
tion has  been  performed  29  times  with  no  deaths  (Scudder).  Once  the 
testicle  was  allowed  to  slough  away  through  a  simple  incision.  The 
cord  was  untwisted  5  times.  This  was  followed  twice  bv  slous-hing  and 
thrice  by  atrophy.     Twenty-three  castrations  were  successful. 

Injury  to  the  Spermatic  Cord. — While  such  injuries  to  the  sper- 
matic cord  as  totally  shut  off  the  blood  supply  of  the  testicle  are  cal- 
culated to  cause  gangrene  of  the  organ,  the  impunity  with  which  the 
cord  may  be  tied  off  is  exemplified  by  numerous  cases  collected  by 
Mauclaire.  This  operation  is,  apparently,  almost  always  followed  by 
simple  atrophy  of  the  testicle,  for  the  blood  supply  to  the  testicle  from 
the  surrounding  fascia  furnishes  sufficient  nutrition  to  prevent  gan- 
grene. 

IRRITABLE  AND  NEURALGIC  TESTICLE 

Irritability  or  neuralgia  of  the  testicle  consists  in  an  abnormal  sen- 
sitiveness of  the  whole  gland  or  of  some  particular  part  of  it.  Mere 
contact  of  the  clothing  may  be  exquisitely  painful.     In  the  recumbent 

^  Presse  med.,  1913,  xxi,  595. 


IRRITABLE  AND  NEURALGIC  TESTICLE  591 

posture  with  nothing  in  contact  with  the  testicle,  the  pain  usually  dis- 
appears. In  other  cases  the  pain  is  constant,  and  perhaps  quite  mild, 
but  increased  by  walking  and  standing  so  as  to  occasion  great  discom- 
fort. The  character  of  the  pain  is  acute  and  darting,  or  heavy  and 
dragging.  The  cremaster  contracts  spasmodically  during  severe  parox- 
ysms, forcibly  retracting  the  testicle.  Between  paroxysms  the  testicle 
is  often  entirely  free  from  pain.  Handling  the  organ  may  perhaps 
induce  a  paroxysm.  The  testis,  sometimes  swollen  and  tense,  is  other- 
wise unaltered.  There  is  no  febrile  reaction.  jSTeuralgia  is  usually 
confined  to  one  testicle. 

Etiology. — ISTeuralgia  of  the  testis,  like  that  of  the  ovary,  has  been 
attributed  to  every  possible  reflex ;  but  certainly  its  most  potent  cause  is 
sexual  excess  or  irregularity,  frequently  that  unchaste  continence  which 
revels  in  the  paraphernalia  of  indecency,  lewd  books,  plays,  tales,  and 
thoughts,  while  seeking  to  hide  beneath  the  cloak  of  physical  propriety. 
Temporary  irritable  testis  may  be  produced  in  a  healthy  person,  at  any 
time,  by  prolonged  sexual  excitement  ungratified.  Add  to  these  physi- 
cal causes  a  neurotic  disposition  and  the  picture  is  complete. 

True  reflex  neuralgia  is  commonly  seen  in  the  course  of  a  renal  colic. 

Lesions  of  the  nerves  and  cord,  notably  tabes,  may  cause  neuralgia. 

It  is  frequently  due  to  vesiculitis  and  to  mild  chronic  epididymitis. 

Course. — These  patients  are  prone  to  become  more  and  more  self- 
centered  and  to  look  upon  their  condition  as  a  pitiable  one,  ascribing  it 
to  loss  of  seminal  fluid — perhaps  to  nocturnal  emissions — to  neither  of 
which  does  it  bear  any  relation. 

Treatment.- — The  cure  depends  chiefly  upon  discovery  and  elimina- 
tion of  the  cause.  But  so  many  of  the  obscure  cases  are  due  to  sexual 
irregularity  and  chronic  inflammation  of  the  internal  genitals  that  the 
following  suggestions  are  of  value : 

1.  The  backbone  of  the  cure  is  sexual  reform.  Sexual  hygiene, 
which  means  strict  purity  of  thought  as  well  as  action,  must  be  insisted 
on.  A  strict  celibacy  is  usually  impossible  to  such  patients,  while  a 
happy  marriage  afl^ords  them  a  natural  antidote  to  the  irritability  of 
their  sexual  apparatus,  and  should  be  urged  relentlessly  if  there  is  any 
decency  left  in  them.  At  the  same  time  the  regulation  of  physical 
hygiene,  exercise,  diet,  fresh  air,  regiilar  hours,  all  must  be  minutely 
arranged. 

2.  Mild  cases  may  be  controlled  by  local  applications  of  10  per  cent 
guaiacol  in  glycerin,  aided  by  a  suspensory  bandage. 

3.  Brilliant  cures  are  sometimes  effected  by  rectal  douching,  mas- 
sage of  the  vesicles,  or  cauterization  of  the  verumontanum  through  the 
posterior  urethroscope. 


592  DISEASES  OF  THE  TESTICLE 


SYPHILIS  OF  THE  TESTICLE 

Syphilis  of  the  testicle  is  a  relatively  common  and  characteristic 
lesion,  which,  like  the  other  visceral  lesions,  is  much  more  often  found 
on  autopsy  than  during  life. 

I  have  record  of  67  cases,  10  of  them  bilateral.  The  following  table 
shows  the  dates  of  onset : 

AGE  CASES 

4  to     7  months 3 

12  to  18        "      5 

2  years 4^ 

3  " 92 

4  "  6 

5  "  1 

6  " 4 

7  "  3 

8  "  1 

9  "  2 

10  "    1 

11  "    4 

12  "    3 

15  "    , 21 

26  "    1 

31  " 11 

Indefinite    17^ 

Total    67 

It  will  be  noted  that,  though  three  of  the  cases  occurred  between  the 
fourth  and  the  seventh  month,  the  lesion  is  not  common  during  the  first 
year ;  though  over  half  of  the  cases  occurred  within  the  first  four  years. 

Yet  the  appearance  of  syphilis  in  both  testicles  is  no  evidence  of  a 
recent  syphilis,  as  shown  by  its  occurrence  once  in  the  fifteenth  and 
once  in  the  thirty-first  year. 

Morbid  Anatomy. — The  French  school,  following  Dron,*  recognize 
a  secondary  epididymitis  and  a  tertiary  orchitis  or  epididymo-orchitis. 
The  distinction  cannot  be  clinically  established.  Of  my  three  earliest 
cases  one  was  distinctly  an  orchitis. 

The  Testicle. — The  syphilitic  testicle  usually  shows  marked  inter- 
stitial sclerosis,  sometimes  considerable  gummatous  infiltration.  Thus 
the  process  is  the  familiar  scleroginnmatous  one.  It  progresses  slowly 
and  painlessly,  often  with  little  gross  change  in  the  organ. 

*  One  bilateral. 
'Three  bilateral. 
•Six  bilateral. 

*  Archiv  gen.  de  med.,  1863,  vol.  ii,  pp.  513,  724. 


SYPHILIS  OF  THE  TESTICLE  593 

Active  gummatous  orchitis,  however,  may  terminate  by  involvement 
of  the  overlying  tissues  and  eruption  through  the  skin,  leaving  a  typical 
gummy  ulcer. 

The  Epididymis. — The  epididymis  alone  may  be  involved  (I  have 
seen  this  but  twice),  though  more  often  the  testicle  is  implicated  as 
well.  The  lesion  is  usually  confined  to  the  globus  major,  which  forms 
a  hard,  solid,  infiltrated  mass  with  a  sharp  edge.  It  caps  the  end  of 
the  testicle,  separated  from  it  by  a  distinct  sulcus,  so  that  the  organ 
seems  to  be  resting  in  a  clam  shell.  Gummatous  nodules  are  very  rarely 
felt  in  the  epididymis.  This  diffuse  infiltration,  sharp-edged,  not  nodu- 
lar and  not  sensitive,  is  very  characteristic  of  syphilis.  The  French 
speak  of  it  as  a  "helmet  crest." 

I  have  in  one  instance  seen  syphilis  begin  in  the  epididymis  as  a 
rounded  nodule,  the  size  of  a  marrow-fat  pea,  and  to  progress  by  the 
addition  of  other  nodules  in  the  epididymis  and  in  the  testicle  itself. 
These  gummata  so  closely  resembled  tubercles  that  the  testicle  was  re- 
moved under  a  mistaken  diagnosis.  Such  rounded  nodules  in  the  epi- 
didymis, however,  are  extremely  rare. 

The  Tunica  Vaginalis. — ^Hydrocele  is  almost  always  present,  but 
the  amount  of  fluid  is,  as  a  rule,  not  very  great.  Adhesive  vaginalitis 
is  found  after  the  fluid  has  been  resorbed  in  the  course  of  a  cure. 

Symptoms. — The  characteristics  of  the  syphilitic  testicle  are  pain- 
lessness and  slow  groivthj  as  a  rule  but  one  testicle  is  palpably  involved. 
It  does  not  attain  a  very  great  size;  it  does  not  ulcerate  through  the 
skin  unless  it  has  been  neglected  for  a  long  time. 

Examination  reveals  a  testicle  wooden  in  hardness.  If  the  epididy- 
mis is  involved,  the  sharp,  clam-shell  edge  of  the  globus  major  (less 
often  the  globus  minor)  can  usually  be  made  out  without  drawing  off 
the  hydrocele  fluid. 

If  there  is  orchitis,  the  testicle  is  either  generally  involved,  evenly 
and  densely  hard,  or  else  it  is  of  uneven  hardness,  with  projecting  small 
gummata. 

The  vas  deferens  was  involved  in  only  one  of  my  cases.  The  gen- 
eral health  is  not  impaired,  but,  if  both  testicles  are  involved,  sexual 
appetite  and  power  are  likely  to  be  lost. 

ISTot  only  is  the  testicle  painless ;  it  usually  actually  loses  its  testicu- 
lar sensation.  Indeed,  the  opposite  apparently  healthy  organ  is  often 
equally  insensitive,  thereby  evincing  unsuspected  implication  in  the 
disease. 

Prognosis. — The  prognosis  is  excellent.  Whatever  part  of  the  par- 
enchyma has  not  been  destroyed  by  sclerosis  will  continue  to  function- 
ate, and  the  testicle  which  has  been  syphilitic  for  years  may  still  secrete 
spermatozoa.  But  the  patient  should  be  warned  that  the  result  of 
treatment  upon  an  enlarged  testicle  may  be  to  cause  such  absorption 


594  DISEASES  OF  THE  TESTICLE 

of  the  syphilitic  tissue  as  to  reduce  the  gland  far  below  its  normal  size, 
while  any  delay  in  instituting  treatment  will  only  make  this  atrophy 
more  marked. 

The  hydrocele  disappears  with  cure  of  the  orchitis. 

Diagnosis. — The  diag-nosis  of  syphilitic  testicle  is  often  easy  from 
the  appearance  of  the  organ  and  the  syphilitic  history.  Exceptionally, 
the  onset  of  the  disease  is  accompanied  by  mixed  infection,  so  that  for 
a  time  the  testicle  is  tender. 

This  mixed  infection  is  not  obviously  connected  with  gonorrhea, 
and  usually  leads  to  the  diagnosis  of  tuberculosis. 

The  irregular  involvement  may  lead  to  a  diagnosis  of  neoplasm; 
but  here  the  general  rule  applies  absolutely :  No  testicle  should  be  re- 
moved for  neoplasm  until  the  patient  has  been  given  the  benefit  of  a 
test  course  of  treatment,  which  test  course  should  imply  medication 
with  salvarsan. 

Treatment. — The  general  treatment  is  along  the  usual  lines.  We 
may  not  expect  to  bring  a  badly  disorganized  testicle  back  to  an  entirely 
normal  condition.  Local  treatment  is  of  no  value.  The  hydrocele  re- 
quires no  treatment.  Ancient  syphilis  of  the  testicle  often  resists  every 
form  of  treatment  short  of  mercurial  injections  and  salvarsan. 


TUMORS  OF  THE  TESTICfLE 

The  conclusions  of  Ewing's  ^  classical  study  of  neoplasms  of  the 
testicle,  wherein  he  classifies  almost  all  these  confusing  and  varied  neo- 
plasms as  teratomata  form  the  foundation  of  our  knowledge  of  this 
condition.    We  quote  him  as  follows : 

In  the  testis  one  encounters  a  wide  variety  of  neoplasms,  from  the  most 
undifJerentiated,  diffusely  growing,  highly  malig-nant,  round  cell  tumors,  up 
to  fully  adult  and  harmless  tissues  and  organs,  all  of  which  appear  to  have 
one  and  the  same  origin,  the  slow  or  rapid  unfolding  of  original  potencies  of 
sex  cells.  These  facts  seem  to  the  writer  wholly  irreconcilable  with  any  relation 
to  an  external  parasite,  but  reveal  in  a  striking  manner  that  most  important 
of  all  facts  known  about  the  origin  of  neoplasms,  that  embryonal  cells  possess 
more  than  any  others  the  essential  factors  in  the  inception  of  tumors.  .  .  . 

Pure  fibroma  arising  from  the  stroma  of  the  testicle  has  probably  been 
observed,  but  is  extremely  rare. 

Pure  leiomyoma  arising  from  smooth  muscle  structures  of  the  epididymis 
or  corpus  Highmori  has  probably  been  observed  in  a  case  of  Trelat's,  but  does 
not  appear  in  recent  literature. 

Chondroma,  myxoma,  lipoma,  rhabdomyoma,  and  carcinoma  have  not  been 
shown  to  exist  apart  from  a  teratomatous  origin.  Primary  lymphosarcoma 
arises  in  the  testicle,  but  its  exact  cells  of  origin  are  as  yet  undetemiined.  It 
may  first  appear  in   the  rete  testis  as  do  teratomata.     Pure  spindle  cell  sar- 

^  Surg.,  Gynec.  and  Obstet.,  March,  1911,  p.  230. 


TUMORS  OF  THE  TESTICLE  595 

coma  probably  arises  in  the  testicle,  but  is  rare  and  its  exact  origin  is  uncertain. 

Alveolar,  large  round  cell,  perivascular,  and  other  forms  of  so-called 
sarcoma  testis  are  of  epithelial  and  teratomatous  origin.  Adenoma  arising  from 
the  spenuatic  tubule  cells  is  a  rare  tumor  occurring  in  atrophic  undescended 
testes. 

Considerable  hyperplasia  but  no  true  tumors  of  the  interstitial  cells  have 
been  observed. 

The  commonest  tumor  of  the  testis  is  an  embryonal  carcinoma  alveolar  or 
diffuse  with  polyhedral  or  rounded  cells  and  often  with  lymphoid  stroma.  These 
tumors  are  probably  one-sided  developments  of  teratomata.  .  .  . 

That  adrenal  tissue  may  appear  in  true  teratomata  is  shown  by  one  of 
Ohkubo's  cases  and  in  the  writer's  case  16,  a  teratoma  testis  in  its  second  recur- 
rence was  indistinguishable  from  many  adrenal  tumors.  Further  evidence 
would  therefore  seem  necessaiy  to  establish  the  occuiTence  of  a  true  testicular 
tumor  arising  from  pure  adrenal  tissue.  .  .  . 

Standing  out  prominently  from  the  maze  of  speculation  in  this  difficult 
field  are  two  main  facts  of  observation. 

Teratoma  testis  arises  almost  invariably  where  the  spermatic  tubules  enter 
the  rete  testis  and  where  some  sex  cells  must  fail  to  realize  their  full  develop- 
ment into  spermatogonia.  Here  is  one  of  those  transitional  areas  where  tumors 
are  prone  to  develop  from  superfluous  and  isolated  cells. 

Teratoma  testis  arises  at  all  ages,^  often  after  trauma,  in  testicles  that 
appear  to  have  been  normal.  The  reasonable  deduction  is  that  all  normal 
testicles  contain  the  potential  cells  of  origin  of  teratomata  and  that  such  rare 
accidents  as  isolation  of  blastomeres  and  fertilization  of  polar  bodies  are  not 
concerned  in  their  origin.  It  must  be  urged  that  no  one  has  ever  seen  anything 
in  the  testicle  which  Avould  directly  connect  teratomata  with  isolated  blastomeres 
or  polar  bodies.  The  existence  of  such  things  in  the  testicle  is  purely 
hypothetical. 

Influenced  by  these  considerations  the  writer  concludes  from  this  study 
that  teratoma  testis  arises  from  sex  cells  in  the  neighborhood  of  the  rete,  whose 
normal  development  into  spermatogonia  has  been  suppressed  but  whose  potencies 
remain  intact  and  ready  to  express  themselves  in  the  various  forms  of  simple  or 
complex  teratomata. 

The  gross  characteristics  of  the  growth  may  be  those  of  a  dermoid 
cyst,  or  of  a  tumor  of  mixed  tissue,  solid  or  cystic,  or  of  a  rapidly 
growing  malignant  growth. 

Secondary  hydrocele  is  a  relatively  unimportant  feature. 

Metastases  occur  early  by  way  of  the  lymphatics.  Later  the  whole 
pampiniform  plexus  of  veins  may  become  involved  in  the  growth. 


SYMPTOMS 

Since  malignant  tumors  of  the  testicle  often  appear  benign  at  the 
outset,  and  since  apparently  benign  tumors  may  at  any  time  become 
malignant,  tumor  of  the  testicle  should  always  be  regarded  as  menacing 
its  possessor's  life.     Thus  in  one  of  Conclie's  cases  (Sturgis)  the  tumor 

^The  great  majority,  however,  between  the  ages  of  15  and  30. 


596 


DISEASES  OF  THE  TESTICLE 


began  to  grow  after  having  been  quiescent  for  five  years.  On  the  other 
hand,  in  a  case  recorded  by  Socin,  in  six  months  the  tumor  attained  the 
size  of  a  man's  head,  and  Sturgis's  case  of  sarcoma  grew  in  a  year  to  the 
size  of  a  child's  head.  Kocher  collected  32  cases,  25  of  which  came  under 
observation  within  a  year  and  a  haK  of  the  beginning  of  the  disease,  and 
of  which  only  1  had  lasted  six  years — an  average  of  one  year  and  four 
months ;  while  83  of  Kober's  ''sarcoma"  cases  show  an  average  of  two 
years  and  eight  months  from  the  beginning  of  the  disease  to  the  time  of 


Fig.  125. — CAScixoiiA  of   Testicle.     The   organ  is  completely  destroyed  by  the  growth. 
There  is  hydrocele.     (Case  of  Dr.  G.  D.  Stewart.) 


operation.     The  pain  is  often  slight  throughout,  though  it  may  well  be- 
come severe  in  the  later  stages.     Testicular  sensation  is  lost. 

The  oval  shape  of  the  testicle  is  preserved.  As  the  tumor  grows  it 
may  be  evenly  elastic  or  uneven,  nodular,  elastic  in  places,  perhaps  fluc- 
tuating when  there  are  large  cysts  or  a  flaccid  hydrocele.  Finally,  the 
scrotal  veins  enlarge,  the  iliac  and  lumbar  glands  can  be  felt  by  deep 
abdominal  palpation,  and,  ultimately,  the  tunica  albuginea  gives  way 
and  elastic  masses  can  be  felt  projecting  through  it.  Thence  the  fascia 
and  skin  are  involved  and  the  tumor  eats  its  way  through  the  tense  in- 
tegument, forming  the  malignant  fungus,  the  fungus  hematoides  of  the 
testicle.  This  occurred  only  once  in  Kober's  114  cases.  The  inguinal 
glands  do  not  enlarge  until  the  scrotum  becomes  invaded  by  the  growth, 
for  the  lymphatics  from  the  testicle  run  directly  up  the  cord  to  the  iliac 
and  lumbar  glands. 


TUMORS  OF  THE  TESTICLE  597 

DIAGNOSIS  AND  TREATMENT 

It  is  well  to  remember  that  every  neoplasm  of  the  testicle  is  pos- 
sibly syphilitic  until  the  contrary  is  proved.  A  short,  sharp  course  of 
treatment  will  decide.  If  this  fails,  any  lump  within  the  testicle 
should  be  treated  as  tumor,  by  operation. 

Curiously  enough  the  more  vascular,  rapidly-growing  type  of  growth 
may  readily  be  mistaken  for  hydrocele.  Twice  in  my  experience  this 
had  led  to  the  unpardonable  use  of  aspiration  for  a  diagnosis. 


CHAPTEK    LXII 
HYDROCELE,  HEMATOCELE,  SPERMATOCELE,  CHYLOCELE 

Hydrocele  is  usually  defined  as  an  accumulation  of  serous  fluid  in 
the  tunica  vaginalis.  Hydrocele  may  also  occur  in  the  funicular  process 
of  the  peritoneum  (encysted  hydrocele  of  the  cord). 

Varieties. — Hydrocele  may  be  idiopathic  or  symptomatic.  It  may 
be  acute  or  chronic.  While  all  idiopathic  cases  are  chronic,  not  all 
symptomatic  cases  are  acute,  therefore  the  terms  are  not  quite  inter- 
changeable. 

SYMPTOMATIC  HYDROCELE 

As  its  name  suggests,  symptomatic  "hydrocele  occurs  only  as  a  symp- 
tom of  disease  in  the  testicle  and  epididymis.  It  is  often  acute,  and  is 
especially  common  with  acute  epididymitis  and  tuberculosis.  A  fibrous 
adhesive  vaginalitis  has  been  identified  post  mortem  or  during  opera- 
tion.    It  gives  no  clinical  symptoms. 

Treatment — The  treatment  of  symptomatic  hydrocele  is,  in  some 
degree,  comparable  to  the  treatment  of  serous  pleurisy.  If  the  primary 
disease  is  acute  and  the  hydrocele  insignificant,  it  may  be  disregarded 
and  allowed  to  be  absorbed  as  the  acute  disease  abates.  If  large  and 
tense,  or  its  absorption  too  slow,  it  may  be  aspirated  one  or  several 
times.  But  if  the  primary  disease  is  chronic,  while  aspiration  may 
hold  the  hydrocele  in  check,  some  more  radical  procedure  is  often  de- 
manded. The  treatment  by  injection  usually  fails.  The  need  of  a 
more  radical  procedure  may  prove  the  surgeon's  opportunity  to  induce 
the  patient  to  submit  to  an  operation  upon  his  testicle  from  which  he 
otherwise  would  shrink. 

IDIOPATHIC  HYDROCELE 

Most  French  writers  maintain  that  there  is  no  such  thing  as  idio- 
pathic hydrocele,  that  every  vaginalite  sereuse  is  symptomatic.  This 
theory  does  not  explain  why  idiopathic  hydrocele  is  so  common  in  the 
tropics,  or  why  idiopathic  hydrocele  does  not  often  follow  acute  epididy- 
mitis, a  disease  which  leaves  far  gTeater  changes  in  the  epididymis  than 
those  alleged  as  cause  of  idiopathic  hydrocele. 

598 


IDIOPATHIC  HYDROCELE 


599 


Varieties. — Hydrocele  is  usually  confined  to  the  tunica  vaginalis 
(Fig.  126).  In  infants,  however,  it  may  occur  before  the  funicular 
process  has  begun  to  close  (congenital  hydrocele) ,  so  that  the  cavity  of 
the  hydrocele  communicates  with  the  peritoneal  cavity,  yet  by  such  a 
small  opening  that  there  is  often  no  hernia  and  the  fluid  does  not  spon- 
taneously drain  off  into  the  abdomen  (Fig.  129).  A  more  frequent 
variety  is  infantile  hydrocele,  occurring  when  the  funicular  process 
has  quite  closed  at  its  upper  end,  so  that  the  fluid  distends  both  vaginalis 
and  funicular  process  (Fig.  130).  Hydrocele  occurring  in  a  retained 
testis  is  termed  inguinal  hydrocele. 
These  and  other  varieties  mentioned 
above  Avill  be  dealt  with  later. 

Etiology. —  Hydrocele  does  not  oc- 
cur as  a  dropsical  phenomenon,  and  it 
has  already  been  distingiiished  from 
inflammatory  or  symptomatic  vaginal- 
itis.  It  is  possible  that  certain  cases 
are  due  to  the  bursting  of  an  epididy- 
mal  cyst  into  the  tunica  vaginalis,^  but 
beyond  this'  we  are  quite  in  the  dark 
as  to  its  cause. 

Hydrocele  is  most  common  in  the 
middle-aged.  In  the  tropics  it  is  said 
to  afflict  one  man  in  ten.  It  is  far  less 
common  in  temperate  climes. 

Pathology — The  Character  of 
THE  Fluid. — The  fluid  of  hydrocele  is 

viscid,     odorless,     straw-colored,     clear.    Fig.  126.— Usual  Form  of  Hydrocele. 

or    opalescent.      It    looks    like    blood 

serum.  Its  specific  gravity  is  about  1.024.  It  contains  about  6  per 
cent  of  organic  matter,  notably  fibrinogen,  to  which  it  owes  its  property 
of  coagTilating  blood  serum.  The  alkaline  carbonates  and  sodium 
chlorid  are  present  in  some  quantity.  The  reaction  is  neutral.  The 
presence  of  fibrinogen  and  inorganic  salts  distinguishes  it  from  ascitic 
fluid.  It  may  contain  a  few  flakes  and  strings  resembling  urethral 
shreds.  It  is  sometimes  full  of  bacteria,  sometimes  brown  from  the 
admixture  of  blood.  These  bacteria  and  this  blood  are  usually  the 
result  of  previous  punctures.  The  microscope  reveals  blood  and  epithe- 
lial cells  and  leukocytes.  Cholesterin  crystals  are  usually  present,  not 
often  in  any  numbers.     Suppuration  is  rare. 

The  Quantity  of  Fluid. — A  good-sized  hydrocele  contains  some 
200  or  300  c.c.  of  fluid.  Mr.  Cline  removed  6  quarts  from  the  scrotum 
of  Gibbon  the  historian.    Breisson,  after  removing  16  liters  on  one  occa- 

*  Lancet,  1885,  i,   748. 


600    HYDROCELE,  HEMATOCELE,  SPERMATOCELE,  CHYLOCELE 

sion,  drew  26  liters  from  the  same  patient  ten  months  later.  It  takes 
from  three  months  to  a  year  for  a  good-sized  hydrocele  to  refill  after  tap- 
ping. The  largest  hydroceles  I  ever  operated  upon  held  2,500  c.c.  and 
1,500  c.c.  (right  and  left  sides  of  the  same  patient). 

The  Tunica  Vaginalis.^ — The  sac  of  a  hydrocele  may  remain  nor- 
mal in  structure  even  after  the  disease  has  existed  for  some  time. 


Fig.  127. — Radiogram  of  Calcified  Tunica  Vaginalis. 

Support  to  the  testicle  and  systematic  tapping  may  prolong  this  condi- 
tion indefinitely.  But  if  the  scrotum  is  not  supported,  the  slight  bruis- 
ing which  the  tumor  continually  suffers  may  produce  a  chronic  thicken- 
ing in  the  tunica  vaginalis;  the  surface  loses  its  gloss  and  becomes 
wrinkled  and  irregular,  while  the  vaginalis  becomes  thick  and  leathery. 
Adhesions  and  masses  of  fibrin  result  from  inflammation.  Obliteration 
of  some  part  of  the  sac  may  subdivide  it,  causing  the  rare  multilocular 
hydrocele.  I  have  twice  met  with  calcification  of  the  vaginalis^  a  very 
rare  condition,  which  has  been  exhaustively  described  by  Eoswell 
Park.^ 

^Jour.  of  Cut.  and  Gen.-Urin.  Diseases,  1895,  xiii,  361. 


IDIOPATHIC  HYDROCELE  601 

The  Testicle  and  Epididymis. — Unless  inverted  or  displaced  by 
adhesions,  the  testicle  lies  below  and  behind  the  hydrocele.  In  mild 
cases  the  testicle  remains  normal,  but  after  evacuation  of  the  fluid  one 
or  more  areas  of  induration  may  commonly  be  found  in  the  epididymis. 
These  are  points  of  intertubular  edema  due  to  the  interference  with 
circulation.  In  old  and  inflamed  cases  of  hydrocele,  both  testis  and 
epididymis  may  be  quite  sclerosed  and  so  atrophied  as  to  be  scarcely 
recognizable  in  the  sac  wall.  Sometimes  the  tunica  vaginalis  forces 
its  way  between  the  testicle  and  epididymis,  forming  quite  a  pouch 
there. 

Multilocular  Hydrocele. — Multilocular  hydrocele  is  quite  rare.  It 
may  be  produced  in  one  of  three  ways : 

1.  Several  varieties  of  hydrocele  exist  simultaneously  (e.  g.,  hydro- 
cele of  the  vaginalis  and  hydrocele  of  the  cord). 

2.  The  sac  becomes  subdivided  by  adhesions. 

3.  There  is  hernia  of  the  sac  between  testis  and  epididymis. 
Fibrous    Bodies. — The   so-called    fibrous   bodies    occasionally   met 

with  upon  opening  a  hydrocele  are  concretions  of  earthy  phosphates 
or  carbonates  covered  with  fibrin.  Probably  they  are  for  the  most  part 
due  to  a  deposition  of  the  hydrocele  salts  upon  some  warty  growth, 
followed  by  atrophy  of  the  little  nucleus,  after  which  the  concretion 
breaks  free.  Wendlung  met  with  concretions  6  times  in  109  opera- 
tions (Peraire^).  They  do  not  exceed  the  size  of  a  pea — though 
Chassaignac  found  one  2  cm.  long  and  12  mm.  wide — and  are  usually 
single. 

Symptoms. — Idiopathic  hydrocele  is  always  chronic.  The  effusion 
takes  place  slowly  and  painlessly,  and  the  swelling  is  only  discovered 
after  it  has  attained  some  size,  for  which  reason  the  patient  fancies  it 
has  appeared  suddenly.  The  accumulation  of  fluid  is  slow  and  inter- 
rupted, but  continues  indefinitely.  After  tapping,  the  reaccumulation 
is  at  first  rapid  and  then  slow  until  the  tumor  reaches  its  original  size, 
usually  several  months  after  tapping.  Thus  I  have  a  patient  who,  re- 
fusing any  radical  measures,  returned  twice  a  year  for  11  years  to  be 
tapped,  having,  for  a  number  of  years  previous  to  that  date,  visited 
other  surgeons  for  the  same  purpose. 

There  are  no  subjective  symptoms  attached  to  hydrocele,  except  the 
sensation  of  dragging  felt  in  the  loin  and  groin  from  the  weight  of  the 
tumor. 

Signs. — Hydrocele  is  usually  pear-shaped,  larger  below  than  above ; 
or  it  may  be  oval,  and,  if  very  large,  sausage-shaped.  It  cannot  be  re- 
duced by  pressure.  Fluctuation  can  usually  be  made  out.  The  tumor 
is  generally  tense,  the  scrotum  often  stretched  and  shining.  The  cord, 
of  natural  size  and  feel,  can  be  grasped  above  the  tumor.     The  testicle 

^Bull.  de  la  soc,  anat.,  1899. 


602  HYDROCELE,  HEMATOCELE,  SPERMATOCELE,  CHYLOCELE 

is  usually  situated  behind,  a  little  below  the  center  (Fig.  126),  and 
pressure  on  this  point  gives  rise  to  the  peculiar  sensation  experienced 
when  the  testicle  is  squeezed.  Occasionally  the  testicle  is  found  below 
and  in  front,  more  rarely  in  the  center,  in  front,  from  plastic  adhesion. 
Its  position  should  always  be  ascertained  before  operating  on  a  hydro- 
cele. Pressure  on  a  hydrocele  does  not  produce  pain ;  there  is  no  heat 
or  redness  of  the  skin  unless  the  tumor  be  large  enough  to  keep  it  con- 
stantly on  the  stretch.     There  is  flatness  on  percussion.     There  is  no 


Fig.  128. — Hydrocele. 

impulse  on  coughing,  unless  the  hydrocele  extends  into  the  inguinal 
canal  or  is  complicated  by  hernia. 

The  weight  of  the  tumor  is  a  criterion  that  has  been  much  depended 
upon  to  disting-uish  solid  from  fluid  tumors.    It  is  absolutely  unreliable. 

Varicocele  and  hernia  may  complicate  hydrocele,  and  the  pressure 
on  the  testicle  may  render  it  sterile.  But  if  the  hydrocele  is  cured  the 
testicle  will  resume  its  functions  unless  it  has  become  atrophied. 

Diagnosis. — The  diagnosis  is  made  by  three  tests : 

1.  The  light  test. 

2.  Isolation  of  the  tumor. 

3.  Puncture. 

The  Light  Test. — Most  hydroceles  are  so  thin-walled  that  if  an 
electric  bulb  or  a  candle  is  held  close  to  one  side  of  the  tumor  and  the 
opposite  side  inspected  through  a  tube  (e.  g.,  a  roll  of  paper),  the  whole 
mass  glows  with  a  pinkish  light.  The  position  of  the  testicle  may  even 
be  discerned  by  its  shadow. 


CONGENITAL  HYDROCELE 


603 


This  test  rules  out  hematocele,  most  spermatoceles,  and  solid  tumors 
of  the  testicle,  but  does  not  exclude  a  complicating  hernia. 

If  the  walls  of  the  hydrocele  are  thickened,  the  light  test  fails. 

If  the  test  fails  in  a  case  that  has  every  other  aspect  of  hydrocele,  it 
is  doubtless  a  spermatocele. 

Isolation  of  the  Tumor. — If  the  fingers  can  be  brought  together 
above  the  tumor  and  feel  nothing  but  the  normal  tissues  of  the  cord, 
hernia  is  excluded. 

If  the  tumor  runs  into  the  inguinal  canal  and  gives  no  impulse  on 
coughing,  there  is  probably  no  hernia. 

PuNCTUKE. — The  tumor  should  not  be  punctured  unless  hernia  can 
be  absolutely  excluded  by  isolation,  and  tumor  by 
the  light  test.     It  is,  in  other  words,  both  dangerous 
and  unnecessary. 

Prognosis. — Hydrocele  in  the  adult  does  not  get 
spontaneously  well. 

Suppuration  and  transformation  into  hemato- 
cele are  rare.  Curling  cites  the  case  of  a  Spaniard 
"who  had  ruptured  his  hydrocele  thirty  times  by 
horseback  riding  and  other  violent  exercises ;  yet  the 
swelling  always  returned  after  a  few  months.  In- 
fants often  get  well  spontaneously,  and  expectant 
treatment  is  therefore  most  suitable  for  them. 

Treatment — Tapping. — This  is  appropriate  to 
symptomatic  hydrocele,  for  children — for  whom  it 
is  often  curative — and  for  patients  refusing  radical 
measures.    Before  tapping  for  hydrocele  the  testicle  must  be  accurately 
located  by  the  testicular  sensation  or  the  light  test,  and  hernia  and 
tumor  must  be  absolutely  excluded. 

Hydrocele  in  the  adult  will  usually  refill  after  this  operation,  but 
for  children  it  often  suffices,  especially  if  the  internal  surface  of  the  sac 
be  scratched.  If  the  cyst  wall  be  thick  tapping  will  never  effect  a  cure. 
The  patient  can  put  on  a  suspensory  bandage  and  resume  work  at  once 
after  tapping. 

Radical  Treatment. — Of  the  many  methods  of  treating  hydrocele 
only  two  need  be  detailed — namely,  injection  and  open  operation. 
The  choice  between  these  operations  is  discussed  in  Chapter  LXXX. 


Fig.   129.  —  Congen- 
ital Hydrocele. 


CONGENITAL  HYDROCELE 


In  congenital  hydrocele  there  has  been  no  obliteration  of  the  peri 
toneal  prolongation,  and  the  tunica  vaginalis  is  continuous  with  the 
peritoneum  (Fig.  129).     It  occurs  in  infancy. 


604  HYDROCELE,  HEMATOCELE,  SPERMATOCELE,  CHYLOCELE 

Diagnosis. — The  diagnosis  is  usually  easy,  but  there  is  some  danger 
of  confusion  with  hernia. 

Congenital  hydrocele  and  hernia  usually  coexist. 

Congenital  hydrocele  may  be  found  in  adults,  but  is  rare.  Horwitz 
met  with  it  once  in  110  cases.  Kocher  estimates  that  it  occurs  4  times 
in  every  100. 

Treatment. — Open  operation;  never  injection. 


INFANTILE  HYDROCELE 

Infantile  hydrocele  is  far  more  common  than  the  congenital  variety. 
Horwitz  met  with  22  cases.  The  hydrocele  occupies  the  tunica  vaginalis 
and  the  funicular  process  up  to  the  inguinal  canal,  where  it  is  shut  oft" 
from  the  general  peritoneal  cavity  (Fig.  130).  It  resembles  a  con- 
genital hydrocele,  but  is  quite  irreducible. 

Treatment. — Since  these  hydroceles  are  usual- 
ly complicated  by  hernia,  they  should  never  be 
injected,  always  subject  to  open  operation. 

Abdominal  Hydrocele  (Bilocular  hydrocele^ 
hydrocele  en  hissac). — This  is  a  very  rare  variety 
of  infantile  hydrocele,  in  which  the  hydrocele  is 
partly  in  the  scrotum,  partly  in  the  abdomen.  The 
abdominal  portion,  which  may  grow  to  an  enor- 
mous size,  usually  lies  between  the  general  peri- 
toneal cavity  and  the  anterior  abdominal  wall.  By 
Fig  130— I nf an-  pi'^ssing  the  abdominal  muscles  the  patient  can 
TILE  Hydrocele.  force  the  fluid  violently  into  the  scrotum. 

Treatment. — Excision  of  the  sac.  I  have 
operated  upon  one  case  in  which  the  tumor  reached  to  the  umbilicus. 
The  sac  was  readily  freed  through  an  abdominal  incision.  It  was  then 
readily  drawn  down  and  excised  through  an  incision  over  the  inguinal 
canal.     The  canal  was  then  repaired  by  the  Bassini  method. 


ENCYSTED  HYDROCELE  OF  THE  CORD 

Conditions  commonly  grouped  as  encysted  hydrocele  of  the  cord  are : 

1.  Hydrocele  of  the  processus  funicularis. 

2.  Pedunculated  cysts  of  the  epididymis. 

3.  Hydrocele  of  an  old  hernial  sac. 

1.  Hydrocele  of  the  Processus  Funicularis The  sac  is  shut  off 

below  from  the  tunica  vaginalis,   above  from  the  peritoneum.      The 
hydrocele  may  be  single  or  multiple.     Usually  single,  it  presents  the 


MULTILOCULAR  HYDROCELE  OP  THE  CORD  605 

features  of  a  hydrocele  of  the  tunica  vaginalis,  but  is  situated  above 
the  testicle  and  about  the  vas.  Sometimes  it  may  be  reduced  into  the 
inguinal  canal,  but  never  into  the  abdomen.  Although  it  usually  occurs 
in  children,  I  have  several  times  seen  it  in  the  adult. 

2.  (See  below.) 

3.  Hydrocele  of  an  Old  Hernial  Sac — This  occurs  in  the  proces? 
of  peritoneum  left  behind  by  a  hernia  which  has  been  reduced  and  the 
neck  of  the  sac  closed,  either  spontaneously  or  by  the  use  of  the  injec- 
tion cure  for  hernia.  The  hydrocele  is  usually  mistaken  for  a  recurrence 
of  the  hernia. 

Treatment. — The  sac  should  be  incised  and  its  parietal  layer 
removed. 

Hematocele. — Hematocele  of  the  cord  is  rare,  but  may  occur  in 
the  same  way  as  hematocele  of  the  tunica  vaginalis,  usually  after  injury. 
Indications  for  treatment  are  the  same  (p.  608). 


MULTILOCULAR  HYDROCELE  OF  THE  CORD 

Multilocular  hydrocele  of  the  cord  was  first  described  by  Pott  and 
Scarpa  as  diffuse  hydrocele  of  the  cord,  and  most  authors  retain  that 
title.  The  pathogenesis  of  this  rare  affection  is  habitually  misunder- 
stood. Kocher,^  however,  after  a  critical  survey  of  the  literature,  con- 
cludes that  an  actual  diffuse  hydrocele  can  be  due  only  to  a  rupture  of 
some  hydrocele  or  spermatocele,  a  temporary  accumulation  of  fluid  in 
the  connective  tissue  about  the  cord.  All  other  cases  he  classifies  under 
five  heads,  viz. : 

1.  Echinococcus  cyst. 

2.  Spermatocele. 

3.  Encysted  hydrocele  of  the  cord  subdivided  into  loculi  by  ad- 
hesive inflammation. 

4.  Cysts  of  fetal  remains  (Miiller's  Duct,  Wolffian  Body,  Organ  of 
Giraldes). 

5.  Cystic  lymphangioma. 

Symptoms. — The  symptoms  are  characteristic,  whatever  the  nature 
of  the  disease.  The  tumor  extends  about  the  cord  from  the  testis  up  or 
into  the  speiinatic  canal.  It  is  smooth,  rounded,  translucent,  and  boggy 
rather  than  fluctuating,  though  a  difference  in  this  regard  may  be  made 
out  in  different  parts  of  the  tumor.  It  may  be  partly  reducible.  There 
is  a  slight  impulse  on  coughing. 

Diagnosis. — The  diagnosis  from  encysted  hydrocele  of  the  cord  is 
established  by  the  boggy  feel  and  the  irregular,  indistinct  outlines  of  the 
tumor.     In  fact,  it  resembles  an  incarcerated  omental  hernia  in  every- 

^Op.    cit.,    pp.    170,    180. 


606  HYDROCELE,  HEMATOCELE,  SPERMATOCELE,  CHYLOCELE 

thing  but  its  translucency  and  its  fluctuation  in  places.    Incision  may  be 
required  to  establish  the  diagnosis. 

Treatment. — The  tumor  may  safely  be  let  alone.  To  cure  it  incision 
has  usually  been  employed.  Pott's  classical  case  of  lymphangioma  died 
of  lymphorrhagia  after  incision. 


CYSTS  OF  THE  EPIDIDYMIS— SPERMATOCELE 

This  condition,  commonly  known  as  spermatocele  or  encysted  hydro- 
cele of  the  testicle,  is  a  collection  of  fluid  "contained  in  a  cyst  or  cysts, 
distinct  from  but  close  to  the  cavity  of  the  tunica  vaginalis"  (Jacob- 
son),  These  cysts  are  developed  in  and  about  the  epididymis,  very 
exceptionally  in  the  testicle  itself,  and  should  be  classified  as  epididymal 
cysts.     Two  classes  may  be  recognized : 

1.  Small  cysts  developing  (usually)   about  the  epididymis. 

2,  Large  cysts  originating  within  the  epididymis. 

1.  The  small  cysts  are  rarely  encountered  before  middle  age,  while 
they  are  very  common  in  later  life.  They  usually  project  more  or  less 
distinctly  from  the  head  of  the  epididymis.  They  do  not  attain  any 
notable  size ;  they  rarely  contain  spermatozoa^in  short,  they  have 
little  clinical  significance. 

2.  The  large  cysts  usually  appear  before  middle  age  and  commonly 
contain  spermatozoa.  They  are  often  multiple  and  grow  between  the 
epididymis  and  the  testicle,  separating  them  and  unraveling  the  former. 
Thus  they  form  irregular  fiuid  tumors  about  the  top  of  the  gland.  Ex- 
ceptionally, the  cysts  are  pedunculated  and  gTow  upward,  simulating 
hydrocele  of  the  cord. 

I  have  seen  four  cases  that  precisely  simulated  hydrocele  of  the  tu- 
nica vaginalis  in  every  respect  except  translucency.  The  sac  lay  in 
front  of  the  testicle  with  the  vaginalis  between. 

These  cysts  rarely  contain  more  than  100  c.c.  of  fluid,  though  Curl- 
ing drew  off  32  ounces  from  one  individual  and  40  ounces  from  another. 
Jacobson  mentions  a  case  from  whose  right  side  49  ounces  were  drawn, 
and  58  from  the  left.  Frost's  ^  cases  yielded  52  ounces.  The  nature 
of  these  large  cysts  is  identified  by  the  fact  that  the  fluid  is  milky  and 
swarming  with  spermatozoa  or  else  absolutely  watery. 

Pathogenesis, — Since  the  smaller  cysts  are  met  with  later  in  life 
than  the  larger,  and  less  frequently  contain  spermatozoa,  many  authors 
attribute  the  larger  cysts  to  persistent  fetal  remains,  such  as  the  vasa 
aberrantia,  the  hydatid  of  Morgagiii,  or  the  paradidymis  (organ  of 
Giraldes),  and  the  smaller  cysts  to  dilatations  of  the  seminal  canals. 
The  recent  tendency,  however,  has  been  to  discredit  the  claims  of  the 

\Lancet.   ]878.  ii.  4.«2 


CYSTS  OF  THE  EPIDIDYMIS— SPERMATOCELE  607 

fetal  elements,  and  to  attribute  the  earlier  and  larger  cysts  to  dilatation 
of  the  vasa  efferentia  or  of  the  epididymis  itself  behind  an  obstacle  more 
or  less  impervious/  and  the  later,  smaller  tumors  to  a  cystic  enlarge- 
ment of  the  tubules  due  to  senile  changes  after  the  organ  has  passed 
the  height  of  its  activity. 

The  presence  of  spermatozoa  in  the  cysts  is  explained  by  those  who 
cling  to  the  theory  of  embryonal  rests  upon  the  ground  that  the  cyst 
has  burst  into  the  epididymal  canal.  The  absence  of  spermatic  elements 
is  explained  by  those  of  the  opposite  camp  on  the  ground  that  the 
cysts  become  occluded  from  the  main  channel  and  their  seminal  ele- 
ments gradually  disintegrate.  The  communication  between  a  cyst  and 
a  seminal  duct  has  been  observed  a  number  of  times. 

Symptoms. — The  small  cysts  are  occasionally  met  with  in  older  men. 
They  produce  no  symptoms. 

The  large  cysts  have  peculiar  features.  If  seen  early,  an  undefined 
sense  of  thickening,  with  extra  resistance,  is  distinguishable  by  the  fin- 
ger in  the  region  of  the  top  of  the  testicle.  This  goes  on  increasing, 
usually  at  so  slow  a  rate  that  the  patient  soothes  himself  with  the  idea 
that  it  will  become  no  larger.  It  grows  constantly,  however,  and  may 
attain  a  large  size.  There  is  no  pain,  except  a  slight  dragging  on  the 
cord.  The  cyst  keeps  its  position  at  the  upper  end  of  the  testicle,  or  ex- 
tending down  in  front  of  it.  It  may  be  "heart-shaped,"  the  testicle 
lying  below  the  cyst  which  is  notched  above.  The  walls  are  usually 
thin  and  tense,  so  that  fluctuation  cannot  always  be  distinguished. 
Translucency  is  rarely  present. 

The  cyst  tends  to  increase  in  size  indefinitely.  It  may  coexist  with 
hydrocele  and  be  masked  by  it.  It  may  be  broken  into  the  vaginalis  by 
accident,  and,  continuing  to  secrete,  form  spermatic  hydrocele,  or  it  may 
be  punctured  when  a  supposed  simple  hydrocele  is  tapped. 

Diag'nosis — The  heart  shape  of  the  cyst,  though  pathognomonic 
when  present,  is  not  constant.  The  diagnosis  is  usually  made  by  the 
irregular  shape  and  position  (above  the  testicle)  of  the  tumor  or  the 
absence  of  translucency  in  a  supposed  hydrocele.  Aspiration  usually 
completes  the  diagnosis  by  withdrawing  a  milky  fluid  full  of  sperma- 
tozoa. If  the  fluid  is  limpid  it  may  be  distinguished  from  hydrocele 
fluid  by  its  watery  limpidity  (whereas  hydrocele  fluid  is  straw-colored), 
its  neutral  reaction,  its  low  specific  gravity  (less  than  1.010),  and  its 
low  percentage  of  albumin  (about  \  per  cent  against  4  per  cent  to  7  per 
cent  in  hydrocele). 

*  Griffiths  {Jour,  of  Anat.  and  Phys.,  1893-94,  xxviii,  107)  maintains  that,  like 
hydronephrosis,  these  dilatations  are  caused  by  partial  obstruction  due,  in  this  case, 
to  catarrhal  inflammation.  He  also  maintains  that  the  hydatid  of  Morgagni  is 
always  a  solid  body,  never  cystic,  and  that  there  is  no  evidence  that  embryonal 
remains  are  in  any  way  connected  with  spermatocele. 


608  HYDROCELE,  HEMATOCELE,  SPERMATOCELE,  CHYLOCELE 

Treatment. — The  cyst  should  be  excised.    There  is  no  object  in  dis- 
turbing small  cysts. 

HEMATOCELE 


The  term  hematoma  is  applied  to  a  tumor  caused  by  the  effusion  of 
blood  into  the  tissues,  whether  of  the  testis  or  the  scrotum.  If  the  effu- 
sion becomes  encysted,  or  if  it  occurs  within  a  cyst  or  the  serous  tunic  of 


Fig.  131. — Hematocele.     The  sac  is  filled  with  hardening  jelly;  hence  the  mosslike  fringe. 
The  slight  thickening  at  the  bottom  is  all  that  remains  of  the  testicle. 

testicle  or  cord,  hematocele  results  (Fig.  131).  I  have  seen  a  hemato- 
spermatocele. 

Etiology. — The  most  common  cause  is  a  crushing  injury.  Any  op- 
eration upon  the  testis  may  result  in  hematocele. 

Scrotal  hematocele  and  testicular  hematocele  are  always  traumatic. 
Vaginal  hematocele  is  usually  traumatic,  but,  exceptionally,  may  have 
a  spontaneous  origin. 


CHYLOCELE  609 

Symptoms. — There  are  consequently  two  varieties.  Tlie  one  comes 
on  rapidly  after  injury  and  is  attended  by  scrotal  hematocele.  If  there 
has  been  a  pre-existing  cyst  or  hydrocele  this  becomes  suddenly  larger, 
more  tense,  and  painful. 

In  the  other,  or  spontaneous  variety,  the  tumor  increases  slowly  in 
size  and  simulates  hydrocele,  except  in  regard  to  translucency. 

The  blood  in  hematocele  may  be  found  red  and  fluid,  but  is  usually 
black  or  brown,  and  it  may  be  mixed  with  pus  if  severe  inflammation 
has  followed  its  effusion.  The  walls  of  the  cyst  may  be  coated  with 
layers  of  fibrin,  and  they  tend  to  thicken  and  become  adherent  to  the 
surrounding  connective  tissue,  while  the  inner  surface  becomes  rough 
and  uneven,  resembling  anything  but  a  serous  surface. 

Diagnosis. — The  diagnosis  of  hematocele  of  the  second  or  spontane- 
ous variety  presents  many  difficulties.  Here  there  is  no  guide  in  the 
history  nor  any  local  signs  of  injury.  The  records  of  surgery  possess 
many  cases  where  perfectly  healthy  testes,  surrounded  by  a  hematocele 
inside  of  a  thickened  tunica  vaginalis,  have  been  extirpated  as  can- 
cerous.    The  diagnosis  cannot  be  made  without  an  exploratory  incision. 

In  the  traumatic  variety,  the  diagnosis  is  made  at  once  from  the 
history.  It  is  unimportant,  often  impossible,  to  distinguish  between 
traumatic  hematocele  of  testis,  vaginalis,  and  scrotum. 

Treatment. — For  hematoma  all  that  can  be  done  is  to  keep  the  pa- 
tient upon  his  back,  with  the  testicle  supported  and  covered  with  cold 
lotions,  administering  an  anodyne  if  the  pain  be  severe.  If  the 
quantity  of  blood  effused  is  not  too  great,  the  pain  will  soon  begin  to 
subside,  and  the  patient  may  be  allowed  to  go  about  with  a  suspensory 
bandage.     The  blood  will  gradually  be  absorbed. 

If,  in  spite  of  these  means,  the  pain  becomes  excessive,  and  the 
tension  of  the  parts  great,  the  tumor  should  be  incised  and  drained. 

Ancient  hematocele  demands  castration. 


CHYLOCELE 

Chylocele  (fatty,  milky,  chylous  hydrocele,  galactocele)  is  an  ac- 
cumulation in  the  tunica  vaginalis  of  chyle  or  fatty  lymph.  It  is  a 
feature  of  lymph  scrotum,  and  is  caused  by  the  rupture  of  a  dilated 
lymph  vessels  into  the  tunica  vaginalis.  Filarial  embryos  have  been 
seen  in  the  fluid  by  Martin  and  Davies.  Chylocele  may  also  be  due  to 
traumatic  rupture  of  a  lymphatic  into  the  tunica  vaginalis.  False 
chylocele  is  due  to  a  fat-  or  cholesterin-producing  degeneration  in  the 
fluid  or  in  the  epithelium  of  a  hydrocele. 

Chylocele  when  occurring  without  lymph  scrotum  resembles  hemato' 
cele.     The  treatment  is  excision. 


CHAPTEK    LXIII 
DISEASES  OF  THE  VAS  DEFERENS  AND  SPERMATIC  CORD 

ANATOMY 

The  cord  is  made  up  of  the  vas  deferens,  the  habenula  or  remains 
of  the  funicular  process  of  the  peritoneum,  and  certain  vessels  and 
nerves,  all  held  together  by  meshes  of  connective  tissue  containing  un- 
striped  muscular  fiber  (internal  cremaster  of  Henle).  Surrounding 
these  is  a  continuous  layer  of  connective  tissue  (tunica  vaginalis  com- 
munis) adherent  to  the  tunica  vaginalis  below  and  continuous  with  the 
fascia  transversalis  above.  Outside  of  this  the  cremaster  muscle  lies 
in  loops,  some  of  them  embracing  the  testicle,  others  extending  only  a 
short  distance  down  the  cord. 

The  arteries  are,  the  spermatic  from  the  aorta,  the  deferential  from 
the  superior  vesical,  and  the  cremasteric  from  the  epigastric.  The 
veins  from  the  testicle  and  epididymis  unite  in  the  pampiniform  plexus 
which  constitutes  the  bulk  of  the  cord.  The  larger  veins  have  valves; 
they  usually  unite  within  the  abdomen  to  form  one  large  trunk,  which 
empties,  on  the  left  side  into  the  renal  vein,  on  the  right  side  into  the 
vena  cava.  A  much  smaller  bundle  of  veins  accompany  the  vas  and 
the  spermatic  artery.  The  spermatic  plexus  of  nerves  is  derived  from 
the  renal,  the  aortic,  the  superior  mesenteric,  the  hypogastric,  and  the 
lumbar  plexuses  of  the  sympathetic,  the  genital  branch  of  the  genito- 
crural  nerve,  and  the  inguinal  branch  of  the  ilio-inguinal. 

The  cremaster  muscle  varies  in  size  and  power  in  different  subjects. 
Its  function  is  to  assist  in  sustaining  the  testicle  by  its  tonic  contrac- 
tion, and  to  compress  the  organ  during  the  sexual  orgasm.  The  muscle 
is  subject  to  painful  spasmodic  contraction  in  kidney  colic,  in  neuralgia 
of  the  testicle,  and  sometimes  in  connection  with  prostatic,  or  vesicular 
irritation.  The  cremasteric  reflex  is  the  retraction  of  the  testicle  excited 
by  irritation  of  the  adjoining  portion  of  the  thigh. 

The  Vas. — The  vas  deferens  is  the  excretory  duct  of  the  testicles. 
It  runs  upward  from  the  tail  of  the  epididymis  to  form  one  of  the  main 
constituents  of  the  spermatic  cord.  It  lies  in  the  inner  and  posterior 
portion  of  the  cord,  where  it  may  be  identified  as  a  rigid  tube,  the  only 
element  of  the  cord  that  does  not  slip  almost  insensibly  from  between 

610 


VARICOCELE  611 

the  examining  fingers.  After  passing  tlirougii  the  inguinal  canal  the 
vas  curves  obliquely  downward  and  backward  over  the  base  of  the 
bladder,  crosses  behind  the  ureter  and  runs  to  the  inner  side  of  that 
duct,  separated  from  it  by  the  seminal  vesicle.  At  this  point  it  becomes 
markedly  sacculated,  forming  the  ampulla  of  the  vas,  then  narrows 
to  its  original  dimensions,  and  is  joined  by  the  duct  of  the  seminal 
vesicle  to  form  the  ejaculatory  duct,  which  pierces  the  prostate  and 
opens  into  the  posterior  urethra  just  in  front  and  to  one  side  of  the 
verumontanum. 

The  vas  deferens  is  lined  throughout  with  columnar  epithelium. 
Its  muscular  coat  consists  of  two  layers,  the  inner  circular,  the  outer 
longitudinal.     Surrounding  all  is  a  dense  fibrous  tissue. 

Relations. — The  chief  relations  of  the  vas  have  been  described 
above.  In  the  scrotum  it  is  closely  surrounded  by  its  own  artery  and 
one  or  two  small  veins.  These  vessels  and  the  nerves  run  near  it,  and, 
except  for  a  few  veins  to  the  inner  side,  the  whole  pampiniform  plexus 
lies  to  its  outer  side. 

Anomalies. — Curling  ^  relates  a  number  of  cases  reported  by  various 
authors,  in  which  the  vas  deferens  was  absent  wholly  or  in  part,  on  one 
or  both  sides.  When  the  testicular  end  is  missing  the  epididymis  may 
or  may  not  be  missing  as  well. 

Wounds. — Wounds  of  the  cord  may  cause  profuse  hemorrhage 
and  rupture  of  the  vas.  The  hemorrhage  may  be  checked  readily 
enough.  If  the  vas  is  cut  it  should  be  united  by  Belfield's  method 
(p.  777).  If  some  such  operation  is  not  performed,  the  duct  becomes 
occluded,  and,  although  this  does  not  cause  atrophy  of  the  testicle,  yet 
it  shuts  off  the  spermatozoa  of  that  side  from  the  urethra. 

Complete  division  of  the  cord  may  cause  atrophy  of  the  testicle. 
Division  of  the  pampiniform  plexus  causes  only  a  temporary  edema. 

Torsion  of  the  Cord. — (See  p.  589.) 

Inflammation. —  (See  p.  568.) 

Hydrocele  and  Hematocele. —  (See  p.  604.) 


VARICOCELE  2 

Varicocele  is  varicosity  of  the  veins  of  the  pampiniform  plexus.  It 
may  be  either  symptomatic  or  spontaneous. 

Symptomatic  Varicocele. — Symptomatic  varicocele  is  rare.  It  is 
caused  by  the  pressure  of  some  intra-abdominal  growth  obstructing  the 
spermatic  veins.  The  tumor  is  usually  of  renal  origin  and  malignant 
(p.  492).      ' 

^"Diseases  of  the  Testis,"  4th  ed.,  1878,  p.  7. 

*Cf,   Istomin,   Deutsche  Zeitschr.   f.   Chir.,   1909,   xcix,   1. 


612      DISEASES  OF  VAS  DEFERENS  AND  SPERMATIC  CORD 

Diagnosis. — Symptomatic  varicocele  cannot  be  mistaken  for  spon- 
taneous varicocele.  It  develops  very  rapidly,  late  in  life,  on  either 
side;  is  painless,  attains  large  proportions,  and  is  associated  with  a 
palpable  abdominal  tumor,  against  which  the  treatment  should  be 
directed. 

Spontaneous  Varicocele. — Varicocele  in  a  mild  form  is  perhaps 
the  most  common  affection  of  the  genital  organs.  It  has  been  esti- 
mated that  about  10  per  cent  of  males  have  slight  varicocele.^  It  occurs 
almost  invariably  on  the  left  side;  when  very  marked  on  this  side  it 
may  exist  slightly  on  the  right.  Breschet,  in  120  operations,  operated 
only  once  on  the  right  side.     I  have  never  operated  on  both  sides. 

Most  slight  varicoceles  are  encountered  in  young  unmarried  men; 
the  affection  rarely  commences  after  twenty-five;  ii  is  unusual  to  find 
it  in  a  married  man  whose  sexual  relations  are  satisfactory.  The  chief 
factor  in  its  production  is  ungratified  sexual  desire,  unrelieved  erotic 
fancies,  or,  less  often,  the  opposite  condition,  abuse  of  the  sexual 
powers,  by  which  the  veins  are  kept  constantly  engorged.  The  slight 
turgescence  of  the  veins  constituting  varicocele  in  a  young  bachelor 
and  often  causing  him  needless  alarm,  disappears  after  marriage, 
together  with  the  uneasy  sensations  which  accompanied  it. 

Old  men  whose  testicles  are  inactive  rarely  have  varicocele,  though 
their  legs  show  many  tortuous  veins.  This  fact  is  of  the  utmost  im- 
portance. That  slight  varicocele  is  often  a  sexual  derangement,  a  func- 
tional disorder  depending  upon  vicious  sexual  hygiene,  is  not  suf- 
ficiently appreciated  by  practitioners.  In  many  cases  young  men  dis- 
tress themselves  unceasingly,  and  importune  their  surgeons  for  an 
operation  to  cure  a  disorder  which  would  be  more  speedily  and  effectu- 
ally removed  by  marriage. 

The  degree  of  varicocele  alluded  to  above  may  be  dismissed  briefly. 
The  vessels  are  a  little  full,  the  cord  loose,  feeling  like  a  small  bundle 
of  earthworms,  no  one  vessel  being  exceptionally  large;  the  testicle  is 
perhaps  oversensitive,  and  there  is  usually  a  slight  dragging  sensation 
in  the  groin,  but  beyond  this  nothing  except  the  fancied  ills  and  the 
hypochondriacal  complainings  of  the  young  man  who  is  cheating  'Na.- 
ture  or  abusing  her  gifts.  The  proper  treatment  of  such  cases  is  sexual 
hygiene.  The  patient's  mind  must  be  diverted,  he  must  be  dissuaded 
from  an  operation,  told  to  wear  a  snugly  fitting  suspensory  bandage, 
and  as  far  as  possible  to  forget  his  sex  until  marriage  affords  him  an 
opportunity  to  get  well.  The  free  local  application  of  cold  water  daily 
is  a  very  useful  adjuvant. 

Yet  varicocele  serious  enough  to  constitute  a  disease  and  to  demand 
active  surgical  measures  for  its  relief  does  occur.     It  is  an  exaggera- 

*  Bennett  estimates  7  per  cent.,  while  Senn  states  that  among  9,815  recruits 
2,075  were  affected  with  varicocele. 


VARICOCELE  613 

tion  of  the  milder  form;  it  comes  on  in  early  manhood,  and  has  no 
connection  with  varices  of  the  legs  or  anus  (hemorrhoids). 

Pathogenesis.  — Any  theory  to  be  adequate  must  explain  the  preva- 
lence of  the  disease  among  the  adolescent  and  its  occurrence,  almost 
entirely,  upon  the  left  side. 

Many  authors  look  for  an  anatomical  predisposing  cause.  Thus 
certain  French  writers  invoke  a  pre-existing  phlebitis.  Bennett  ^  and 
Spenser  "  suppose  a  congenital  anomaly  of  the  veins.  Such  predis- 
posing causes  are  not  generally  accepted.  Sufficient  anatomical  pre- 
disposition is  found  in  the  position  of  the  veins,  dependent,  unsup- 
ported, surrounded  by  the  loosest  kind  of  a  fascial  envelope.  To  this 
add  the  congenital  congestion  set  up  by  the  untamed  and  pampered 
passions  of  youth,  and  no  further  predisposing  cause  is  necessary. 

But  why  should  the  varicocele  occur  upon  the  left  side  ?  To  an- 
swer this  question  an  infinite  variety  of  theories  has  been  proposed. 
There  is  space  to  enumerate  only  the  more  important  ones.  The  left 
testis  hangs  lower  than  the  right,  and  the  left  renal  vein  is  higher  than 
the  opening  in  the  cava  which  receives  the  right  spermatic  vein,  hence 
the  left  vein  is  longer  than  the  right.  To  this  add  the  fact  that  the 
left  spermatic  vein,  enters  the  renal  vein  at  right  angles,  and  is  not 
affected  by  suction  as  is  the  right  vein  which  enters  the  cava  at  an 
acute  angle.  So  far  we  are  on  safe  anatomical  ground;  beyond  all 
is  theory.  Perhaps,  as  has  been  alleged,  right-handed  men  transmit 
the  force  of  their  exertions  to  the  left  foot  by  means  of  the  abdominal 
muscles  of  the  left  side.  Bat  I  have  seen  left-handed  men  with  vari- 
cocele, always  on  the  left  side.  Perhaps  the  sigmoid  flexure,  over- 
loaded with  feces,  presses  upon  the  veins.  But  this  is  as  rare  in  youth 
when  varicocele  is  common,  as  it  is  common  in  old  age  when  varicocele 
does  not  oc(3ur.  Curiously  enough  the  ovarian  veins  are  very  rarely 
varicose,  except  on  the  left  side. 

A  violent  strain  may  induce  acute  varicocele. 

Pathology. — In  mild  cases  the  veins  are  merely  tortuous  and  di- 
lated. But  in  a  full-formed  varicocele  the  vessels  are  elongated,  their 
valves  broken  down,  their  walls  affected  by  fatty  atrophy,  and  thickened. 
The  veins  sometimes  contain  phleboliths,  or  become  thrombosed 
throughout,  as  a  result  of  phlebitis. 

Symptoms.  — I  have  seen  a  number  of  cases  of  acute  varicocele  re- 
sulting from  straining,  or  coming  on  spontaneously. 

Except  in  acute  cases,  such  as  those  just  detailed,  varicocele  comes 
on  gradually,  and  is  discovered  by  accident.  The  amount  of  pain  com- 
plained of  varies  greatly ;  a  very  large  varicocele  is  usually  attended 
by  absolutely  no  pain,  while  a  very  slight  enlargement  of  the  veins 

^"On   Varicocele,"   London,    1891. 
•    ^St,  Barthol.  Hasp.  Bep.,  1887,  p.  137, 


Gil      DISEASES  OF  VAS  DEFERENS  AND  SPERMATIC  CORD 

may  give  rise  to  considerable  uneasiness  extending  up  the  back  and 
down  the  thigh,  perhaps  amounting  to  neuralgia  of  the  testis. 

The  only  general  symptoms  of  varicocele  besides  pain  are  those  of 
hypochondria  and  defective  morale.  The  impotence  often  alleged  by 
physicians  of  an  incredible  "years'  experience"  to  result  from  vari- 
cocele is  the  veriest  fiction.  When  impotence  and  varicocele  co-exist 
they  are  due  to  the  same  causes;  but  neither  is  the  impotence  due  to 
the  varicocele  nor  the  varicocele  to  the  impotence. 

The  local  conditions  are  typical.  The  left  testicle  hangs  consider- 
ably lovv^er  than  the  right,  borne  down,  and  perhaps  completely  sur- 
rounded by  the  mass  of  dilated  veins.  The  mass  feels  soft,  like  a  bunch 
of  earthworms.  The  scrotal  veins  may  be  similarly  affected.  The 
scrotum  is  thin  and  relaxed,  the  dartos  powerless.  In  long-standing 
cases  of  severe  varicocele  the  testis  gradually  atrophies  because  of  the 
interference  to  its  circulation.  This  result  is  in  no  way  due  to  the 
weight  of  the  mass  of  veins. 

The  course  of  the  disease  is  usually  not  progressive.  Of  the  many 
men  who  have  slight  varicocele,  only  the  smallest  percentage  fail  to 
get  well  under  the  regulated  sexual  exercise  of  married  life.  Excep- 
tionally, however,  the  veins  do  grow  and  enlarge  indefinitely. 

DiagTiosis.^ — There  are  few  diseases  more  readily  recognizable  than 
varicocele;  the  peculiar  appearance  and  wormy  feel  of  large  tortuous 
veins  can  scarcely  be  confounded  wdth  anything  else. 

Treatment.  — If  the  varicocele  be  small  and  its  symptoms  inconsid- 
erable, the  patient  should  be  advised  as  to  his  sexual  hygiene,  perhaps 
instructed  to  wear  a  suspensory  bandage  and  treated  for  neuralgia  of 
xhe  testicle,  if  this  is  a  feature  of  his  condition.  If  these  measures 
fail,  or  if  the  patient  insists  upon  more  radical  treatment,  surgery  must 
be  employed  (p.  777). 


TUMORS  OF  THE  CORD 

Cystic  Tumors. — See  Hydrocele  of  the  Cord  (p.  604). 

Solid  Tumors — Solid  tumors  of  the  cord  are  rare.  Fibroma, 
fibromyoma,  and  sarcoma,  all  of  the  vas  deferens,  have  been  observed 
in  isolated  instances.  Gumma  is  very  rare  (Goldenberg).^  The  only 
tumor  of  clinical  importance  is  lipoma  of  the  cord.  The  frequency  of 
lipoma  of  a  hernial  sac  lends  color  to  the  theory  that  lipoma  of  the 
cord  is  secondary  to  hernial  lipoma.  In  structure  the  tumor  may  be 
a  pure  lipoma,  a  fibrolipoma,  or  a  myxolipoma. 

These  tumors  are  usually  small  and  reducible  into  the  ingiiinal 
canal,  simulating  epiplocele,  from  which  they  are  only  differentiated 

^Jour.  of  Cut.  and  Gen.-Urin.  Diseases,  1901,  xix,  113. 


TUMORS  OF  THE  CORD  615 

by  operation,  unless  they  can  be  drawn  entirely  out  of  the  canal.  Ex- 
ceptionally, however,  they  attain  an  extraordinary  size.  Nove-Josse- 
rand  ^  reports  a  specimen  weighing  6^  kilos,  and  cites  two  others  weigh- 
ing respectively  20  and  15  pounds.  The  larger  tumors  may  be  patho- 
logically benig-n  and  yet  clinically  malignant. 
^Lyon  med.,  1897,  Ixxxiv,  237. 


CHAPTER   LXIV 

DISEASES  OE  THE  SEMINAL  VESICLE 


ANATOMY 

The  seminal  vesicle  (Fig.  132)  is  a  reservoir  connected  with  the 
vas  deferens.  Each  vesicle  lies  to  the  outer  side  of  its  vas,  its  apex 
buried  in  the  prostate,  where  it  joins  the  vas  at  an  acute  angle  to  form 
the  ejaculatory  duct.     The  body  of  the  vesicle  is  directed  obliquely 

upward  and  outward,  lying  along 
the  upper  border  of  the  prostate 
and  projecting  beyond  it  laterally. 
The  fundus  of  the  vesicle  lies  just 
external  to  the  termination  of  the 
ureter  in  the  bladder.  Each  ves- 
icle is  bound  close  to  the  bladder 
and  prostate  by  the  fascia  of  Den- 
onvilliers,  a  dense  envelope.  This 
fascia  is  the  relic  of  that  portion 
of  the  peritoneum  that  in  the  fetus, 
separates  the  budding  bladder 
from  the  rectum.  It  begins  at  the 
apex  of  the  prostate,  covers  the 
posterior  surface  of  this  gland, 
forms  the  posterior  sheath  of  the 
seminal  vesicles  and  merges  into 
the  peritoneal  reflection  above. 
Within  this  fascia  ramify  numer- 
ous large  branches  of  the  prostatic  plexus  of  veins.  The  relation  of 
the  vesicles  to  the  peritoneum  is  variable.  The  rectovesical  pouch 
touches  the  fundus  of  each  vesicle ;  when  the  bladder  is  full  there  is  a 
triangular  extraperitoneal  space  between  the  vesicles,  just  above  the 
prostate. 

The  vesicle  is  elliptical  in  shape,  flattened  anteroposteriorly.    Guel- 

liot  ^  gives  49,  18.5,  and  10  mm.  as  its  average  length,  breadth,  and 

thickness.     The  lumpy  surface  of  the  vesicle  has  been  compared  to  the 

convolutions  of  varicose  veins  or  of  the  intestine.     By  a  tedious  and 

^"Pes  vesicules  seniinales, "  Paris,  1883,  p.  27. 

61^ 


132. — Seminal  Vesicles. 


PHYSIOLOGY  617 

delicate  dissection  the  vesicle  may  be  unraveled.  It  is  a  canal  10  to  15 
cm.  long.  From  this  canal  spring  numerous  small  diverticula,  one  of 
which,  originating  near  the  orifice  of  the  organ,  may  be  almost  as  long 
as  the  vesicle  itself.  The  blind  end  of  the  vesicular  tube  may  be 
doubled  back,  so  that  the  tube  actually  terminates  near  the  orifice  of  tne 
vesicle,  and  the  fundus  represents  its  middle. 

The  tube  is  quite  as  irregTilar  within  as  without.  Here  and  there 
the  orifices  of  diverticula  loophole  the  tortuous  wall. 

The  vesicle  is  made  up  of  three  coats:  a  thin  outer  fibrous  coat,  a 
thick  middle  layer  of  circular  and  longitudinal  muscular  fibers,  and  a 
mucous  membrane.  This  contains  many  elastic  fibers.  Its  epithelium 
is  cylindrical  in  youth,  cuboidal  or  flattened  in  old  age.  The  epi- 
thelial cells  often  contain  granules  of  brownish  pigment,  masses  of 
which  are  occasionally  found  in  the  semen.  Guelliot  denies  the  exist- 
ence of  special  glands  in  the  vesicle,  and  affirms  that  the  epithelium  is 
identical  throughout  the  organ.     Rehfisch  recognizes  vesicular  glands. 

The  arteries  of  the  vesicle  are  derived  from  the  inferior  vesical  and 
the  middle  hemorrhoidal.  The  veins  join  the  prostatic  and  lateral  ves- 
ical plexus.  The  lymphatics  empty  into  the  pelvic  ganglia.  The  nerves 
are  derived  from  the  hypogastric  plexus  of  the  sympathetic. 

The  ejaculatory  ducts  begin  at  the  junction  of  the  vas  deferens  and 
seminal  vesicle.  Becoming  smaller  and  of  even  caliber,  these  ducts  run 
obliquely  forward  and  upward  through  the  prostate,  approaching  each 
other  until  they  nearly  touch  in  the  median  line.  Yet  they  are  quite 
separate  in  their  openings  on  the  lips  of  the  prostatic  utricle.  They  are 
closely  surrounded  by  a  dense  elastic  tissue  and  contain  a  few  straggling 
muscle  fibers  derived  from  the  longitudinal  muscle  of  the  vesicle. 


PHYSIOLOGY 

The  functions  of  the  vesicle  are  three: 

1.  To  store  the  secretion  of  the  testis. 

2o  To  dilute  it. 

3.  To  expel  it  into  the  prostatic  sinus  just  before  ejaculation. 

1.  Rehfisch,^  in  a  detailed  study  of  the  comparative  anatomy  and 
physiology  of  the  seminal  vesicles,  showed  that  in  rats,  guinea-pigs, 
and  some  other  mammals,  the  vesicles  empty  by  a  separate  duct  into  the 
urogenital  sinus  and  at  no  time  contain  spennatozoa.  But  he  confirmed 
on  man  De  Graaf's  experiment  of  injecting  the  vas  deferens,  showing 
that  the  vesicle  fills  with  fluid  before  the  ejaculatory  duct  is  forced  open. 
Hence  it  is"  fair  to  assume  that  the  vesicle,  as  well  as  the  ampulla  of  the 
vas,  is  a  place  of  storage  for  the  spermatozoa. 

^Deutsche  med.  Wochenschr.,  1896. 


618  DISEASES  OF  THE  SEMINAL  VESICLE 

2.  The  secretion  of  the  seminal  vesicle  dilutes  the  semen  and  prob- 
ably has  some  obscure  function  of  stimulating  the  vitality  of  the  sper- 
matozoa. This  secretion  is  albuminous,  alkaline,  and  odorless.  It  con- 
tains a  large  proportion  of  mucin.  Besides  blood  cells,  leukocytes,  and 
epithelia,  the  fluid  contains  many  little  hyaline  pellets  rarely  visible  to 
the  naked  eye.  These  bodies  (sympexions,  globulin  korner)  appear 
under  the  microscope  as  hyaline  spheroids  showing  radiating  lines  of 
cleavage.  They  may  contain  masses  of  spermatozoa  or  pig-ment  gran- 
ules, and  may  attain  a  size  sufficient  to  obstruct  the  ejaculatory  duct. 

3.  The  vesicle  becomes  distended  with  fluid  by  the  accumulation  of 
its  own  secretion  and  the  influx  of  testicular  fluid.  Unless  there  is 
spermatorrhea,  little  or  none  of  this  fluid  escapes,  except  during  the 
sexual  orgasm.  This  act  occurs  as  follows :  after  a  period  of  sexual 
excitement,  during  which  the  verumontanum  becomes  erect,  the  mus- 
cular coat  of  the  vesicle  and  the  ampulla  of  the  vas  contract  peristal- 
tically,  driving  the  fluid  into  the  ejaculatory  duct,  which,  very  probably, 
is  relieved  of  the  elastic  pressure  that  usually  occludes  it  by  a  simul- 
taneous muscular  contraction  of  the  prostate.  The  semen  is  thus  ejacu- 
lated into  the  prostatic  sinus,  where  it  mingles  with  the  prostatic  secre- 
tion. Thence  the  prostatic  and  urethral  muscles  eject  the  fluid  by  jets. 
Regurgitation  of  semen  into  the  bladder  is  prevented,  not  by  the  erect 
verumontanum  but  by  the  force  of  the  stream  issuing  from  the  ejacu- 
latory ducts. 

Science  and  experience  agree  that  the  seminal  vesicles  are  not 
emptied  by  a  single  orgasm. 


ANOMALIES 

Anomalies  of  the  seminal  vesicles  are  usually  part  of  some  general 
genital  malformation.  Guelliot  has  analyzed  and  refused  to  accept 
the  alleged  cases  of  multiple  seminal  vesicles.  When  the  vesicle  is 
absent  the  corresponding  testicle  may  yet  be  present.  Extreme  dilata- 
tion of  the  vesicles  is  probably  always  acquired. 

The  ejaculatory  ducts  may  empty  into  the  ureters  instead  of  on 
the  edge  of  the  prostatic  utricle.  In  a  few  cases  they  have  been  found 
to  continue  forward  alongside  of  the  urethra  the  whole  length  of  that 
canal  to  the  meatus. 


WOUNDS  OF  THE  VESICLE 

Guelliot  recognizes  only  one  ease  of  undoubted  accidental  wound  of 
the  vesicle.     The  patient  had  suffered  a  fracture  of  the  ischium. 


CONCRETIONS  AND  CALCULI  619 

Operative  wounds  of  the  ejaculatory  ducts  are  very  frequent.  The 
patency  of  the  ducts  is  imperiled  by  all  perineal  cystotomies  and  pros- 
tatotomies,  including  lithotomy,  Bottini's  operation,  and  prostatectomy. 
Two  results  follow:  inflammation  (acute  vesiculitis  and  epididymitis) 
possibly,  obstruction  probably. 

Fistulae  of  the  spermatic  duct  have  resulted  from  the  old-fashioned 
lateral  lithotomy  operations.  The  resultant  spermatic  fistula  heals 
kindly  unless  the  parts  are  cancerous  or  tuberculous. 


EXAMINATION  AND  INFLAMMATION 

(See  pp.  8,  165,  176,  182.) 

TUBERCULOSIS 

(See  p.  438.) 

CYSTS 

Prolonged  inflammation  sometimes  causes  gradual  dilatation  of  the 
vesicles  until  they  become  two  or  three  times  their  normal  size  and  even 
overlap  in  the  median  line.  Such  cysts  have  only  a  pathological  sig- 
nificance. 

E chinococcus  cysts  occurring  between  rectum  and  bladder  have  been 
attributed,  without  convincing  proof,  to  the  vesicle. 

CONCRETIONS  AND  CALCULI 

While  it  is  not  unusual  to  find  a  number  of  concretions  or  small  cal- 
culi in  the  vesicles  of  the  aged,  they  have,  as  a  rule,  no  clinical  symp- 
toms. It  is  only  very  rarely  that  they  give  rise  to  spermatic  colic  or 
attain  a  noteworthy  size  (Fig.  32). 

Symptoms.— ^permfth'c  colic  may  occur  at  the  moment  of  ejacula- 
tion or  during  sleep.  The  pain  is  very  sharp,  colicky,  in  fact,  and 
nauseating.  It  is  centralized  about  an  inch  up  the  rectum,  or  at  the 
neck  of  the  bladder,  and  thence  radiates  up  the  posterior  wall  of  the 
pelvis  or  to  the  testicles.  The  pain  is  caused  by  the  impaction  of  a 
concretion  or  a  mass  of  inspissated  semen  in  the  duct.  The  obstruction 
may  be  forced,  and  a  painful  and  deficient  emission  ensue  after  a  few 
moments  of  colic,  or,  if  it  occur  without  sexual  sensations,  during  the 


620  DISEASES  OF  THE  SEMINAL  VESICLE 

night,  it  lasts  from  ten  to  twenty  minutes  and  then  gradually  dies 
away. 

Treatment. — The  hot  rectal  douche  (p.  244)  is  an  excellent  remedy 
to  relieve  the  pain  and  to  shorten  the  attack.  Many  persons  who  are 
subject  to  mild  attacks  of  nocturnal  spermatic  colic  obtain  relief  by 
introducing  a  finger  into  the  rectum  and  pressing  upon  the  offending 
organ. 

Eelapses  are  prevented  by  massage  of  the  vesicle. 


MALIGNANT  GROWTHS 

Guelliot  recorded  but  one  authentic  case  of  primary  carcinoma  of 
the  seminal  vesicle.  Secondary  involvement  occurs  from  the  prostate, 
bladder,  or  rectum. 


CHAPTER   LXT 
DERANGEMENTS  OF  THE  GENITAL  FUNCTION 

IMPOTENCE 

Impotence  is  inability  to  accomplish  the  sexual  act.  It  is  a  com- 
plaint not  infrequently  submitted  to  the  physician ;  not  always  frankly 
find  openly  as  such,  but  often  by  implication,  as  though  it  should  be 
recognized  and  inquired  about  in  answer  to  remote  indications  which 
the  patient  has  scantily  furnished.  The  physician  who  would  meet 
the  daily  wants  of  his  fellow-men  in  reference  to  troubles  of  this  sort, 
must  possess  an  accurate  knowledge  of  the  physiology  of  the  sexual  func- 
tion and  of  its  various  derangements,  and  be  ready  to  anticipate  the 
reticence  of  patients ;  otherwise  he  will  fail  to  sound  many  of  the  depths 
of  human  nature  where  suffering  lurks — which  suffering  is  for  the  most 
part  preventable  or  relievable. 

Impotence  must  be  carefully  distinguished  from  sterility,  which 
signifies  inability  to  beget  offspring  on  account  of  defect  in  the  semen, 
whether  the  individual  can  have  sexual  intercourse  properly  or  not. 
The  two  are  often  associated  in  the  same  individual,  but  they  may  be 
totally  distinct,  as  the  following  examples  will  illustrate.  Thus,  in  the 
East,  there  are  two  methods  of  making  eunuchs :  either  the  penis  is 
removed  together  with  the  testicles  (and  such  a  eunuch  is  necessarily 
both  impotent  and  sterile),  or  the  testicles  alone  are  removed  (and 
such  a  eunuch,  though  sterile,  may  be  still  potent,  and  does  not  bring 
so  high  a  price  as  the  eunuch  who  has  no  penis).  It  is  a  well-known 
fact  that  both  animals  and  men,  from  whom  the  testicles  have  been 
removed  after  puberty,  still  retain  sexual  desires,  and  may  have  inter- 
course, with  venereal  orgasm  and  ejaculation,  during  a  period  of  many 
years.  A  cryptorchid  is  not  impotent,  but  is  very  apt  to  be  sterile,  and 
such  is  the  case  of  many  patients  after  double  gonorrheal  epididymitis ; 
while,  as  causes  of  impotence  without  sterility,  may  be  mentioned  de- 
formities preventing  sexual  intercourse,  though  the  spermatic  fluid  is 
noripal,  such  as  exstrophy  of  the  bladder,  extreme  incurvation  of 
the  penis,  and  hypospadias. 

Impotence  may  be  organic  or  functional. 

621 


622  DERANGEMENTS  OF  THE  GENITAL  FUNCTION 

ORGANIC  IMPOTENCE 

This  is  exceedingly  rare  in  the  male.  Anyone  who  can  perform  the 
sexual  act  is  potent.  This  act  implies  two  conditions,  namely,  suffi- 
cient erection  to  make  intromission  possible  and  a  subsequent  seminal 
ejaculation. 

That  lack  of  desire  before  the  act  and  pleasure  during  its  accom- 
plishment are  not  absolute  essentials  to  sexual  intercourse  is  exemplified 
by  the  two  conditions :  priapism  from  cantharides  in  which  there  is  no 
desire,  and  yet  intercourse  is  possible  with  perfect  intromission  and 
ejaculation,  and  certain  diseases  of  the  cord  attended  by  more  or  less 
priapism,  where  intercourse  followed  by  conception  may  take  place, 
and  yet  the  patient  be  unconscious  at  what  moment  ejaculation  occurs. 

Conditions  Involving-  True  Impotence — 1.  Absence  of  penis.  If 
there  are  healthy  testicles,  the  patient  cannot  be  called  sterile. 

2.  Minute  size  of  penis  may  involve  impotence.  That  small  size  is 
only  relatively  a  cause  of  impotence  is  evident,  and  that  it  by  no  means 
involves  sterility  is  shown  by  Orfila,  in  a  case  where  an  action  for  rape 
was  brought  against  a  man  with  only  a  stump  of  a  glans  in  place  of  the 
entire  penis,  by  a  woman  who  was  impregnated  by  him.  Orfila  decides 
that  impregnation  may  take  place  under  these  circumstances,  but  only 
through  the  consent  of  the  woman,  and  that  consequently  rape  is  im- 
possible. The  numerous  cases  on  record  where  impregnation  has  taken 
place  without  rupture  of  the  hymen  show  that  a  deposit  of  semen  within 
the  ostium  vaginae  may  fertilize  an  ovum,  and  such  a  deposit  of  semen 
might  be  accomplished  by  the  smallest  possible  penis.  Intromission 
and  ejaculation  might  take  place,  and  impotence,  though  possible,  is  not 
essential. 

3.  Extreme  size  of  the  penis  is  a  relative  cause  of  impotence. 

4.  Extreme  epispadias  and  hypospadias,  or  incurvation,  likewise 
involve  impotence,  without  sterility.  Slight  hypospadias  may,  but  does 
not  necessarily,  involve  impotence.  The  semen  is  not  properly  ejacu- 
lated into  the  upper  part  of  the  vagina,  and  impregnation  sometimes 
fails  to  take  place  on  this  account. 

5.  Large  size  of  the  prepuce,  or  excessively  tight  and  narrow  orifice 
of  the  same,  may  involve  impotence,  as  may  also  any  tumors  or  growths 
upon  or  about  the  penis,  elephantiasis,  fatty  tumor,  hydrocele ;  or  neigh- 
boring deformity  (favilty  position  of  the  thigh  from  ankylosis  of  hip, 
excess  of  abdominal  fat,  etc.),  which  may  mechanically  interfere  with 
copulation  without  in  the  least  implying  sterility. 

6.  Very  tight  stricture  of  the  urethra,  especially  if  there  be  large 
and  multiple  fistulae  behind  it,  involves  impotence  if  the  semen  does  not 
escape  by  ejaculation,  but  dribbles  away  after  erection  subsides.  A 
similar  cause  of  impotence  exists  in  a  vicious  direction  of  the  orifices  of 


IMPOTENCE  623 

tlie  ejaculatory  ducts,  by  which  during  ejaculation  the  semen  is  turned 
backward  into  the  bladder  and  escapes  afterwards  with  the  urine.  Ac- 
cording to  Grimaud  de  Caux,  such  a  condition  of  things  may  be  caused 
by  the  action  of  prostitutes,  who,  fearing  pregnancy,  watch  for  the 
moment  of  ejaculation,  and  then  press  forcibly  upon  the  urethra  of  their 
partner  just  in  front  of  the  prostate,  by  inserting  a  finger  into  his 
rectum,  thus  causing  the  semen  to  be  ejaculated  into  che  bladder.  A 
similar  condition  has  been  known  to  result  from  prolonged  posterior 
urethritis  and  is  not  infrequent  after  prostatectomy.  When,  from 
these  or  any  other  causes,  there  is  no  ejaculation,  the  condition  is  known 
as  aspermatism.  I  have  known  two  patients  who  alleged  complete 
aspermia  to  beget  children. 

7.  Imperfect,  irregular,  or  bent  erections,  due  to  inflammation,  in- 
jury, or  tumor  of  one  of  the  erectile  cylinders  of  the  penis,  may  some- 
times prevent  intromission  and  entail  impotence. 

8.  Eunuchs,  and  those  having  atrophy  of  both  testicles,  are  usually 
impotent,  always  sterile. 

9.  Injuries  or  diseases  of  the  central  nervous  system  may  cause 
impotence  by  interfering  v/ith  either  erection  or  ejaculation. 

Impotence  may  be  symptomatic — not  to  speak  of  the  physiological 
impotence  of  childhood  and  old  age — and  then  is  only  conditional  or 
temporary,  and  usually  disappears  with  the  removal  of  its  cause.  In 
symptomatic  impotence  there  is  lack  of  erection,  and  often  also  tem- 
porary sterility.  Such  impotence  is  always  associated  with  severe  acute 
febrile  diseases  and  with  conditions  of  lowered  vitality,  whether  due  to 
wasting  disease,  to  shock,  or  to  other  causes.  Long-continued  sexual 
excess,  whether  by  masturbation  or  otherwise,  produces  impotence, 
though  this  is  commonly  a  false  impotence,  an  inability  of  the  jaded 
body  to  keep  pace  with  the  lecherous  mind.  Finally,  all  drug  habits — 
opium,  tobacco,  cocain,  alcohol,  etc. — tend  to  produce  impotence.  When 
a  man  is  thoroughly  drunk  he  is  impotent ;  when  a  steady  drinker,  his 
sexual  powers  are  always  diminished,  sometimes  lost. 

FUNCTIONAL  IMPOTENCE 

Functional  impotence  is  properly  defined  by  Hiihner  ^  as  "that 
form  of  impotence  in  which  there  exists  no  gross  pathological  change 
in  the  structure  of  the  sexual  apparatus."  It  may  be  considered  under 
three  heads : 

1.  Imaginary  impotence. 

2.  False  impotence. 

3.  Impotence  depending  upon  disease  of  the  sexual  organs  or  abuse 
of  the  sexual  function ;  usually  both  together. 

^Medical  Becord,  October  23.  1915. 


624  DERANGEMENTS  OF  THE  GENITAL  FUNCTION 

Imaginary  Impotence. — The  first  class  may  be  passed  over  lightly. 
Unhappily,  there  will  always  be  among  us  a  class  of  men,  of  splendid 
physique  and  infinite  endurance,  who  elect  to  spend  their  lives  in  ignoble 
homage  to  Venus.  And  such  men  have  their  followers,  their  admirers 
— puny,  dyspeptic,  rabbit-eyed  creatures — whose  sole  ambition  is  to 
flog  their  bodies  on  to  wondrous  feats  of  venery  and  bestiality.  And 
since  Nature  never  cast  them  in  this  mold,  they  come  crying  out  be- 
cause their  bellies  are  not  so  big  as  their  appetites,  instead  of  thanking 
God  for  it. 

False  Impotence. — False  impotence  is  that  purely  psychic  condition 
which  may  result  in  a  perfectly  normal  individual  from  sexual  indif- 
ference or  from  such  emotions  as  grief,  joy,  fright,  repugnance,  etc. 
It  is  only  rarely  that  persons  so  afiiicted  consult  a  physician,  and 
they  can  then  usually  be  relieved  by  a  proper  interpretation  of  their 
symptoms.  A  second  type  of  false  impotence,  however,  exists  in  the 
sexual  pervert  whose  abnormal  habits  have  engendered  a  method  of 
thought  which  renders  normal  cohabitation  repulsive  or  impossible. 
Such  patients  require  the  most  careful  psychotherapeutic  treatment 
which,  with  the  help  of  psycho-analysis,  and  a  sympathetic  under- 
standing of  their  condition,  often  works  wonders. 

Sexual  Neurasthenia — Sexual  neurasthenia,  inasmuch  as  it  implies 
pain  and  discomfort,  has  been  dealt  with  on  page  181.  But  the  lesions 
there  described  centering  about  the  verumontanum  and  utricle  form 
the  physical  basis  of  the  great  majority  of  cases  of  impotence.  The 
patient  may  attribute  his  trouble  to  gonorrhea,  but  it  is  doubtless 
always  due  to  some  sexual  aberration.  In  early  life  the  dominant  cause 
is  masturbation,  later  excessive  sexual  activity  of  any  kind,  and  in 
married  life  coitus  interruptus.  Ungratified  sexual  excitement  is  a 
cause  of  impotence  only  when  carried  to  great  lengths  and  resulting  in 
prolonged  erections  without  emission. 

As  a  result  of  these  conditions  there  may  be  impairment  of  desire, 
psychic  impotence,  disturbances  of  the  orgasm,  usually  in  the  nature  of 
pain,  and  associated  with  other  evidences  of  inflammation  of  the  veru- 
montanum (such  as  painful  urination,  etc.).  Finally,  and  most  impor- 
tant, are  the  disturbances  of  erection  and  ejaculation.  The  condition 
begins  with  frequent  nocturnal  emissions  due  to  hypersensibility  of 
the  sexual  reflex  (usually  caused  by  verumontanitis)  ;  and  premature 
ejaculation  soon  results.  If  the  patient  exercises  prudence  and  intelli- 
gence in  the  management  of  his  sexual  affairs  the  progTess  of  his  con- 
dition may  be  slow  or  he  may  at  any  time  have  the  wit  to  cui3  himself. 

As  the  conditions  grow  worse  the  emission  becomes  so  premature 
that  it  actually  occurs  before  full  erection  takes  place. 

Functional  Impotence — In  diagnosing  functional  impotence  it  is 
to  be  remembered  that  every  case  has  its  psychic  basis,  most  cases  a 


IMPOTENCE  625 

moral   and   a   physical   one.      The   following   suggestions   will   be   of 
assistance : 

1.  True  continence,  chastity  of  thought  as  well  as  of  act,  never  causes 
impotence. 

2.  Delay  and  lack  of  sensation  in  erection  is  likely  to  be  psychic 
rather  than  due  to  sexual  excess. 

3.  The  intense  reticence  of  these  patients,  while  perfectly  natural, 
interferes  with  a  proper  understanding  of  the  case.  Some  form  of 
psycho-analysis  is  often  necessary  to  obtain  all  the  facts,  but  once  the 
physician  has  these  in  his  possession  he  is  in  a  position  to  treat  the  case 
intelligently;  without  the  facts,  he  can  do  nothing. 

4.  The  condition  may  continue  to  develop  after  its  cause,  e.  g.,  mas- 
turbation, has  long  since  stopped. 

Treatment.— The  treatment  is  threefold: 

1.  The  Patient's  Sexual  Coefficient  Must  Be  Discovered. — 
The  sexual  coefficient  is  the  amount  of  sexual  power  with  which  he  is 
endowed  by  Nature,  Mankind  at  large  is  possessed  of  the  notion  that, 
although  men's  noses  and  digestions  need  not  all  be  cut  of  the  same 
pattern,  it  is  to  be  expected  that  the  sexual  capacity  of  everyone  should 
be  all-embracing.  Thus,  while  it  is  no  disgrace  to  be  dyspeptic  about 
the  stomach,  it  is  to  the  last  degree  shameful  to  be  dyspeptic  about  the 
genitals.  Theoretically,  such  a  distinction  is  absurd;  but  practically, 
no  man  is  willing  to  brand  himself  a  sexual  laggard.  In  some  way,  by 
dint  of  enumerating  emissions,  copulations,  masturbations,  the  physi- 
cian must  learn  what  ideal  he  can  set  before  the  patient.  If  a  man's 
natural  capacity  for  sexual  congress  is  only  once  a  month,  it  is  hopeless 
to  try  and  tune  him  up  to  three  times  a  night. 

2.  The  Patient  Must  Be  Encouraged. — The  first  point  of  en- 
couragement must  be  to  depress  him  by  bidding  him  look  for  a  pro- 
tracted and  relapsing  convalescence.  Then  he  must  be  made  to  under- 
stand that  his  sexual  possibilities  are  just  so  gTeat  and  no  greater ;  and 
that,  however  well  he  may  get,  overstepping  his  allotted  bounds  will  call 
down  swift  retribution  upon  him.  Finally,  he  must  really  be  encour- 
aged to  feel  that  his  malady  is  a  functional  disorder,  a  dyspepsia,  which, 
like  other  dyspepsias,  is  curable,  but  only  at  the  cost  of  a  prolonged 
fast.  He  must  abstain  from  coitus,  from  masturbation,  from  lewd 
companions,  from  obscene  thoughts  and  things.  The  more  thoroughly 
he  abstains,  the  more  certain  his  cure.  Usually  he  will  try  to  adopt 
halfway  measures,  caring  more  for  his  "pot  of  ale"  than  for  body  and 
soul  together.  But  such  a  course  may  not  be  countenanced.  The  ideal 
of  absolute  purity  must  be  forever  set  before  him  and,  as  it  were, 
hammered  into  him.  If  a  strong  moral  influence,  as  that  of  father, 
brother,  or  priest,  can  be  brought  to  bear,  so  much  the  better. 

But  all  these  measures  are  frankly  palliative.     When  a  man  has 


626  DERANGEMENTS  OF  THE  GENITAL  FUNCTION 

once  got  into  the  habit  of  concentrating  his  whole  mind  upon  his  sexual 
organs,  it  is  not  to  be  expected  that  he  should  be  entirely  diverted  to 
higher  things.  Chastity  all  can  aim  at,  but  celibacy  is  beyond  the 
reach,  beyond  even  the  understanding,  of  the  many.  Hence,  the  proper 
cure  for  such  a  man,  if  he  can  be  got  into  such  a  condition  that  he  has 
an  erection  ever  so  rarely,  is  to  instruct  him  in  sexual  physiology  and 
hygiene,  to  acquire  his  confidence  by  sympathy,  and  to  get  him  married, 
with  the  advice  to  attempt  no  intercourse,  to  be  entirely  frank  and  hon- 
est with  his  wife  (who  will  more  than  equal  him  in  timidity  and 
ignorance ) ,  and,  awaiting  some  morning  when  awaking  with  a  vigorous 
erection,  to  accomplish  coitus  promptly  without  delay,  as  a  matter  of 
imperious  duty.  The  act  once  accomplished,  the  spell  is  broken.  He 
knows  he  is  a  man  and  his  confidence  in  himself  returns. 

3.  He  Must  Be  Assisted  Physically. — When  possible,  an  entire 
change  of  scene  with  hard  physical  work  presents  the  best  opportunity 
for  a  man  to  get  out  of  his  old  rut. 

Local  treatment  of  the  urethra  by  instillations,  urethroscopic  cau- 
terization, massage  of  prostate  and  vesicles,  sounds,  etc.,  quite  empiric- 
ally, as  in  the  treatment  of  sexual  neurasthenia  (p.  204). 

Hiihner  speaks  well  of  bromids,  1  gin.,  p.  c.  (and  0.0025  (1/20  gr.) 
•of  strychnin  in  four  doses,  q.  2  h.,  immediately  preceding  intercourse). 


STERILITY 

Sterility  is  an  inability  to  beget  children  on  account  of  absence  or 
imperfection  of  the  semen. 

The  spermatic  fluid,  though  ejaculated,  may  contain  no  spermatozoa 
(azoospermia).  Without  enumerating  all  the  possible  causes  of  azo- 
ospermia, three  may  be  especially  desigTiated : 

1.  Obliteration  of  both  epididymes  or  both  vasa  by  inflammation. 

2.  Such  temporary  influences  as  debilitating  disease  and  mental  or 
physical  exhaustion.  The  latter  is  the  cause  of  temporary  sterility  in 
many  business  men.  They  can  impregnate  their  wives  only  after  a 
vacation  has  supplied  them  with  surplus  energy.  Chemical  toxemias 
may  produce  the  same  result,  and  although  alcoholics  are  famous  for 
having  large  families,  Simmons  ^  estimates  that  61  per  cent  of  alco- 
holics are  sterile. 

3.  The  x-ray  -  deserves  special  mention.  Brief  exposure  to  this 
may  entail  brief  sterility.  The  constant  exposure  to  the  influence  of 
the  ray  to  which  radiographers  are  subjected  results  in  a  prolonged 
and  perhaps  a  permanent  sterility. 

^Deutsch.  Archiv  f.  Uin.  Med.,  1898,  Ixi,  412. 

^Cf.  Brown  and  Osgood,  Trans.  Am.  Assn.  G.-TJ.  Surg.,  1907,  ii,  365. 


STERILITY  627 

4.  Inflammation  of  the  prostate  and  vesicles.  If  the  inflammation 
is  severe  the  spermatozoa  may  be  killed  in  transit,  but  even  a  mild 
catarrh  may  so  alter  the  qualities  of  these  secretions  as  to  render  the 
spermatozoa  infertile. 

Oligospennia  is  a  rare  and  apparently  congenital  condition  in  which 
the  semen  instead  of  swanning  with  spemiatozoa  contains  but  few  of 
these.  They  are  usually  deformed.  Such  a  condition  entails  sterility 
just  as  much  as  does  azoospermia. 

Aspermia  means  absence  of  ejaculation  owing  to  defect  or  deformity 
or  scar  about  the  orifices  of  the  ejaculatory  ducts;  these  project  the 
semen  backward  into  the  bladder  instead  of  outward  along  the  urethra. 
The  patient  recognizes  no  ejaculation,  but  usually  there  is  a  slight 
seepage  from  the  meatus  and  such  patients  are  by  no  means  inevitably 
sterile. 

Diagnosis — The  diagnosis  of  sterility  is  a  much  more  complex 
problem  than  the  above  paragraphs  suggest  for  the  problem  includes, 
not  only  the  question  of  masculine,  but  also  that  of  feminine  sterility. 
Moreover  sterility  is  often  relative.  The  diagnosis  of  sterility,  due  to 
such  gross  lesions  as  azoospermia,  oligospermia  or  aspermia,  is  readily 
accomplished  by  the  examination  of  a  condom  specimen.  The  difficult 
problem  is  that  in  which  both  man  and  woman  are  apparently  normal 
though  their  union  remains  infertile.  Careful  microscopic  examination 
of  a  condom  specimen  of  semen  is  the  first  step  in  diagnosis.  The  chief 
inforaiation  obtained  by  such  an  examination  is  the  number  of  sper- 
matozoa. If  these  are  very  numerous  the  semen  is  doubtless  fertile 
even  though  many  of  the  spermatozoa  are  deformed.  Indeed  it  is 
usually  a  waste  of  time  to  endeavor  to  estimate  the  motility  of  the 
spermatozoa  in  a  condom  specimen.  This  can  only  be  fairly  studied 
in  a  specimen  obtained  by  massage  of  the  seminal  vesicles  (and  unfor- 
tunately massage  does  not  always  expel  the  spermatozoa)  or  by  an 
examination  of  the  secretions  in  the  woman's  vagina  a  few  hours  after 
coitus.  Reynolds,^  basing  his  work  on  that  of  Hiihner,  comes  to  the 
followino;  conclusions : 


1.  When  the  spermatozoa  are  abundant  in  number,  normal  in  fonn  and 
appearance,  furnished  with  long  eiHa  and  capable  of  rapid  movement  through 
the  semen  the  male  is  satisfactorily  fertile. 

2.  When  normal  spermatozoa  are  killed  or  lose  vitality  overrapidly  in  the 
secretions  of  the  individual  woman  the  ehemicophysiologie  character  of  her 
secretions  furnishes  an  effective  cause  of  sterility. 

3.  The  alterations  in  a  secretion  which  make  it  fatal  to  the  spennatozoon 
may  be  localized  in  the  vagina,  in  the  cervix,  in  the  body  of  the  uterus,  or  in  one 
or  both  tubes;' and  any  one  of  these  alterations  may  exist  with  normal  secretions 
above  it;  but  an  alteration  in  the  secreting  surface  in  any  of  these  localities 

^Jour.  A.  M.  A.,  1915,  Ixv,  1151. 


628  DERANGEMENTS  OF  THE  GENITAL  FUNCTION 

usually  vitiates  all  the  secretions  below  it,   pi-obably  by  their  necessary  ad- 
mixture. 

4.  When  the  spermatozoa  are  obser\-ed  to  penetrate  without  apparent  loss  of 
vitality  to  the  fundus  of  the  uterus  and  to  sui-vive  there  for  a  normal  length  of 
time,  deficient  quality  of  the  ova  may  be  considered  the  probable  cause  of  the 
sterility. 

Throughout  the  management  of  every  case  of  sterility  it  must  be  remem- 
bered that  the  failure  is  the  failure  not  of  one  individual,  but  of  a  couple,  and 
that  the  condition  of  both  partners  must  be  studied. 

For  the  performance  of  the  Hiihner  test  ^  we  must  ask  to  see  the  woman  as 
soon  as  possible  after  coitus  has  taken  place.  She  may  come  to  the  ofl&ce  for 
this  examination,  since  it  is  only  veiy  exceptionally,  if  ever,  that  the  vagina 
does  not  contain  sufficient  spermatozoa  for  this  test  even  after  she  has  walked 
about  for  some  time.  With  a  noi-mal  vaginal  secretion  the  spermatozoa  should 
show  active  motility  in  the  vagina  for  about  an  hour  and  sometimes  much  longer, 
but  if  circumstances  permit  it  is  desirable  that  the  patient  should  be  seen  within 
half  an  hour  of  coitus.  A  specimen  of  the  vaginal  mucus  is  taken  by  a  sterile 
platinum  wire  from  the  culdesac,  exposed  by  a  speculum,  and  this  examination 
may  be  repeated  if  desired,  whenever  convenience  permits,  until  the  spermatozoa 
are  found  to  have  lost  their  activity.  A  specimen  of  the  cervical  mucus  is 
next  obtained  in  the  same  way,  after  the  surface  of  the  cer^'ix  has  first  been 
carefully  wiped  clean  of  semen  by  the  I'epeated  use  of  cotton  swabs  (no  anti- 
septic should  be  used).  With  a  nornial  cervical  secretion  and  a  normal  os  a  few 
spermatozoa  will  usually  be  found  in  the  lower  part  of  the  cervical  cavity  almost 
immediately  after  coitus,  but  will  appear  there  in  larger  numbers  at  the  end  of 
half  an  hour  to  an  hour.  They  are  never  so  numerous  here  as  in  the  vagina, 
but  under  normal  circumstances,  at  the  end  of  an  hour,  there  should  be  several 
actively  moving  spemiatozoa  in  each  slide  from  the  cervical  mucus.  The 
greatest  care  should  be  used  to  avoid  the  infliction  of  anj'  trauma  in  the  ex- 
amination of  the  cerv'ical  ea\'ity,  since  ovcrthoroughness  here  may  readily  vitiate 
the  use  of  the  remaining  portion  of  the  test  at  that  sitting. 

When  the  cervical  cavity  has  not  been  unduly  disturbed,  when  the  spermato- 
zoa are  of  full  vitality,  and  when  the  secretions  of  the  woman  are  normal 
throughout,  an  examination  of  the  secretions  of  the  cavity  of  the  uterine  body 
should  disclose  the  presence  of  a  few  actively  motile  spemiatozoa  in  the  uterine 
mucus  at  the  end  of  from  two  to  three  or  four  hours.  This  examination  must, 
however,  be  made  with  a  specially  de\'ised  syi-inge,  since  the  platinum  loop  can 
neither  be  introduced  with  certainty  to  the  fundus  nor  made  to  retain  the  uterine 
mucus  during  its  withdrawal  from  the  cervix.  Even  with  the  use  of  a  syringe 
it  is  difficult  to  be  absolutely  sure  that  spermatozoa  which  are  observed  in  the 
fluid  withdrawn  from  the  uterus  are  not  due  to  an  admixture  from  the  cervix, 
but  if  the  piston  is  not  withdrawn  until  the  tip  of  the  syringe  is  well  up  in  the 
uterine  cavity,  if  the  outside  of  the  syringe  is  carefully  wiped  after  withdrawal, 
if  it  is  properly  designed,  and  especially  if  the  spennatozoa  are  found  several 
times  in  succession,  their  probable  location  in  the  uterine  mucus  can  be  predi- 
cated. In  some  cases  it  will  be  found  that  actively  motile  spermatozoa  have 
disappeared  from  the  cervix  after  the  lapse  of  a  number  of  hours  but  are  still 
found  in  the  uterine  mucus.    In  these  cases  the  test  is  practically  complete. 

The   saddest   commentary   upon   the   prevalent   state   of  the   med- 
ical mind   in   reference  to  the   diagnosis  of  sterility   is   reported   by 
^Urol  and  Cutan.  Review,  1914,  xvii,  No.   11;   also  "Sterility,"  1913. 


MASTURBATION  629 

Barney/  He  collected  statistics  from  a  large  public  hospital  on  108 
women  who  were  diagnosed  as  sterile;  74  of  them  were  actually  oper- 
ated upon,  or  advised  to  be  operated  upon,  and  yet  in  only  5  of  the 
whok  number  was  the  husband's  semen  examined. 

Treatment. — Ten  per  cent  of  sterility  is  said  to  be  due  to  the  male, 
and  it  is  only  with  the  treatment  of  sterility  in  the  male  that  we  shall 
concern  ourselves.  I  can  recall  only  three  classes  of  cases  that  have 
consulted  me : 

1.  Aspermia  after  operation  is  likely  to  be  only  temporary,  or  at 
worst  partial.  I  have  twice  tried  to  correct  it  by  operation,  but  have 
not  succeeded.  It  is,  as  above  stated,  not  an  inevitable  cause  of 
sterility. 

2.  Azoospermia  due  to  alcohol  or  overwork.  Cases  of  the  latter 
sort  are,  I  believe,  not  infrequent.  I  have  twice  seen  impregnation 
follow  a  vacation  in  Europe ;  one  of  these  couples  had  been  married 
five  years,  the  other  twenty.  In  both  the  semen  was  apparently  normal 
while  the  husbands  were  at  work,  and  the  wives  had  been  duly  and 
vainly  mutilated  by  the  gynecologist. 

3.  Azoospermia,  due  to  bilateral  gonorrheal  epididymitis.  For 
these  the  proper  treatment  is  the  Martin  operation;  without  it  there 
is  no  hope,  with  it  there  is  a  small  prospect  (perhaps  20  per  cent), 
of  cure. 

I  have  never  seen  a  case  in  which  the  vitality  of  the  semen  appeared 
to  be  interfered  with  by  suppuration  in  the  prostate  or  seminal  vesicles. 
Many  persons  with  chronic  prostatitis  and  seminal  vesiculitis  have  all 
the  children  they  want.  Oligospermia  seems  a  more  incurable  condi- 
tion than  azoospermia,  for  in  the  former  case  the  deficiency  is  probably 
congenital,  though  Martin  regards  it  as  a  partial  obstruction. 


MASTURBATION 

Self-abuse  is  the  production  upon  one's  self  of  the  venereal  orgasm. 
The  term  masturbation  signifies  that  an  orgasm  is  produced  by  means 
of  friction  with  the  hand.  Masturbation  is  not  a  malady.  It  does  not 
necessarily  produce  disease  unless  carried  to  excess.  Its  practice  is  not 
confined  to  man.  Monkeys  are  often  masturbators ;  bears  have  the  same 
habit ;  goats,  making  use  of  the  mouth,  indulge  in  it ;  turkeys  sometimes 
practice  it.  In  the  human  being  it  is  practiced  by  both  sexes  at  all  ages, 
females  being  less  addicted  to  it  than  males.  The  majority  of  women 
have  little  passion,  and  suffer  the  first  approaches  of  a  lover  or  husband 
largely  as  a  matter  of  complaisance.  Undoubtedly  there  are  numerous 
exceptions  to  this  rule,  but  still  a  rule  it  is  that  the  female,  naturally 

^Boston  Med.  4-  Surg.  Jour.,  1914,  clxx,  943. 


630  DERANGEMENTS  OF  THE  GENITAL  FUNCTION 

modest,  retiring,  refined,  learns  wliat  passion  is  only  as  the  result  of 
experience.  With  the  male  it  is  difi'erent.  His  passion  is  natural.  He 
has  erections  while  yet  a  child,  and  sexual  yearnings  long  before 
puberty.  Earely  does  a  boy  escape  initiation  into  forbidden  pleasures 
by  his  schoolfellows  or  his  elders,  and,  though  he  escapes  these,  he  is 
still  very  likely,  when  handling  himself  during  erection,  to  find  the 
sensation  agreeable,  and  to  go  on,  really  ignorant  of  what  he  is  doing, 
until  he  has  become  a  confirmed  masturbator.  Male  babies  are  some- 
times handled  by  their  nurses  to  keep  them  quiet,  a  practice  which  is 
certain  to  be&'et  the  habit  even  in  the  earliest  rears  of  life.  Stone  in 
the  bladder,  irritation  of  the  prepuce  from  retained  smegma,  ascarides, 
etc.,  lead  a  child  to  handle  himself,  and  end  in  masturbation,  if  long 
continued;  indeed,  there  are  so  many  causes,  natural  and  unnatural, 
why  a  boy  should  masturbate  that  few  escape.  But  the  most  common 
cause  is  instruction  received  from  other  boys  at  schooL 

Self-abuse  is  not  confined  to  youth ;  middle  and  old  age  are  not  free 
from  it. 

It  may  be  safely  assumed  that  a  large  proportion  of  mankind  have 
masturbated  more  or  less  at  some  period  in  their  lives,  and  it  is  equally 
safe  to  assert  that  at  least  90  per  cent  of  such  masturbators  are  not 
physically  injured  by  the  habit.  If  carried  to  excess,  sexual  indulgence 
in  the  natural  way  will  produce  evil  eft'ects,  yet  sexual  intercourse  is  not 
only  harmless,  but  even  beneficial  in  moderation,  as  it  can  be  only  in 
the  married  state.  It  is  not  the  loss  of  seminal  fluid  which  is  of  the 
first  importance  in  producing  disease  from  sexual  excess,  but  the  nervous 
shock  of  the  oft-repeated  orgasm.  Babies  and  young  children  lose  no 
seminal  fluid,  women  have  none  to  lose ;  yet,  in  all  of  these,  evil  results 
follow  excess  as  certainly  as  they  do  in  the  male  after  puberty.  It  is 
probable  that  any  succession  of  nervous  shocks  as  sharp  and  decisive  as 
the  sexual  orgasm,  even  although  purely  intellectual,  such  as  joy  or  fear, 
would  shatter  the  vitality  and  nervous  tone  of  an  individual  as  much  as 
masturbation. 

Such  writers  as  Lallemand,  Acton,  Belliol,  make  too  much  of  the 
solitary  vice,  while  quacks  find  here  the  largest  and  most  lucrative  field 
for  their  nostrums.  These  men  scatter  their  books  and  circulars  broad- 
cast over  the  land,  and  often,  under  alluring  titles,  thrust  them  within 
the  eager  grasp  of  the  young,  the  inexperienced,  the  hypochondriacal, 
the  nervous,  overworked,  unmarried  youth,  whose  sexual  needs,  stimu- 
lated by  his  impure  thoughts,  find  no  adequate  relief.  Their  tenets  find 
ample  faith  and  ready  acceptance  in  the  ingenuous  mind,  and  errors 
are  implanted  which  years  of  sober  after-thought  and  experience,  aided 
by  the  physician's  careful  and  conscientious  advice,  are  scarcely  able 
to  eradicate. 

The  use  of  tobacco,  alcohol,  and,  it  might  be  added,  tea,  is  as  wide- 


MASTURBATION  631 

spread  as  the  habit  of  masturbation;  and  each  of  these,  or  certainly 
the  first  two  habits,  probably  inflicts  as  much  injury  upon  the  human 
race  as  does  the  secret  vice.  Yet  who  would  affirm  that  every  man 
who  smoked  would  have  headache,  dyspepsia,  heartburn,  neuralgia, 
intermitting  pulse,  or  would  become  thin,  depressed,  nervous,  sleepless 
— all  of  which  effects  may  be  produced  by  an  excess  of  tobacco ;  or  that 
another  who  drank  liquor  would  necessarily  have  delirium  tremens, 
cirrhosis  of  the  liver  and  kidney,  and  die  with  ascites  and  Bright's 
disease  ?  As  with  whisky  and  tobacco,  so  it  is  with  masturbation  car- 
ried to  excess.  Masturbation  may  contribute  in  producing  the  most 
serious  results,  among  which  idiocy,  insanity,  epilepsy,  dementia,  phys- 
ical prostration,  hypochondria,  impotence,  and  sterilit}^  are  prominent ; 
but  in  such  it  will  be  found  that  some  mental  deficiency  was  the  funda- 
mental difficulty,  masturbation  but  one  of  its  expressions.  Hence  it  is 
evident  that,  while  the  intelligent  physician  must  recognize  the  physical 
evils  masturbation  may  produce,  he  should  boldly  oppose  himself  to  that 
sickly  sentimentality  which  shrouds  in  mystery  one  of  the  failings  of 
our  physical  nature  because  it  involves  the  sexual  function,  and  should 
try  to  face  the  subject  honestly  and  to  handle  it  as  a  scientific  problem. 

The  majority  of  mankind  who  indulge  in  masturbation  do  so  just 
before  and  after  puberty.  At  first  most  of  them  are  ignorant  that  they 
are  harming  themselves,  but  they  soon  find  it  out  by  one  means  or 
another,  and  then  sooner  or  later  give  it  up.  The  longer  and  the 
more  frequently  they  yield  to  the  vicious  habit  the  stronger  does  its 
hold  become,  so  that  in  case  they  escape  the  mental  and  physical  dis- 
orders to  which  excessive  venery  in  extreme  cases  may  give  rise,  still 
they  may  pay  the  penalty  of  excess  by  some  diminution  of  vigor  in 
after-life,  by  upsetting  their  sexual  hygiene,  and  by  establishing  sexual 
necessities  which  they  find  it  difficult  to  satisfy ;  and,  finally,  they  may 
continue  on  through  life  victims  to  a  perverted  sexual  sense,  shunning 
women,  from  whom  they  aver  that  they  derive  no  pleasure,  totally 
wrecked  as  to  their  morale,  hypochondriacal,  and  suffering  from  all 
sorts  of  functional  distress,  physical  and  intellectual,  real  and  fancied. 

The  chief  reason  why  so  much  is  said  of  venereal  excess  by  mastur- 
bation, and  so  little  of  sexual  excess  in  the  natural  way  is  that  the 
fonner  is  so  much  more  common,  and  not  that  the  act  itself  is  physic- 
ally more  harmful.  The  solitary  vice,  as  it  is  aptly  styled,  may  be 
practiced  on  all  occasions.  On  the  other  hand,  sexual  intercourse  re- 
quires the  consent  of  two  individuals  and  opportunities  which  are  com- 
paratively hard  to  find. 

In  married  life  excess  is  the  exception;  sexual  hygiene  is  more  apt 
to  be  coiTCct,  man  is  in  his  natural  condition.  Other  emotions  enter 
largely  into  his  daily  life,  and  it  is  rare  ihat  a  man  happily  married 
complains  of  any  disorder  of  the  genito-urinary  system,  except  those  of 


632  DERANGEMENTS  OF  THE  GENITAL  FUNCTION 

a  purely  physical  nature.  On  the  other  hand,  the  old  rounder,  who 
flatters  himself  upon  the  number  of  women  he  has  ruined,  but  lays  the 
blame  upon  Dame  Nature,  is  usually  a  masturbator  and,  not  infre- 
quently, a  pervert. 

Symptoms. — A  young  child  who  has  been  taught  to  masturbate  will 
be  seen  constantly  at  work  at  his  genitals,  and  observed  to  have  erections 
with  unnatural  frequency.  N'o  further  signs  are  needed.  Such  chil- 
dren are  fretful,  peevish,  thin,  nervous,  excitable,  sleep  badly,  and  have 
a  haggard  look. 

Boys  who  masturbate  to  excess  usually  incline  to  melancholy  breed- 
ings, to  staying  apart  and  reading  rather  than  to  joining  their  com- 
panions at  play.  Their  palms  are  apt  to  be  cold  and  moist.  They  lose 
the  innocent  frankness  of  youth. 

The  young  man  is  overshy,  unambitious,  he  shrinks  from  a  steady 
gaze,  blushes  readily,  and  seems  to  be  conscious  of  having  done  some- 
thing unmanly. 

Adult  masturbators  often  show  no  sign  of  the  habit,  though  they 
are  apt  to  be  cowardly,  mean-spirited,  poor  specimens  of  humanity. 
But  it  is  rare  for  adults  to  practice  masturbation  to  great  excess,  and, 
if  they  suffer  from  any  of  the  supposed  evil  consequences  of  the  habit, 
it  is  either  on  account  of  excess  in  earlier  life,  of  imperfect  sexual 
hygiene,  or  of  irregTilarly  gratified  sexual  desire.  Their  symptoms 
assume  a  multiplicity  of  expression,  and  are  generally  hypochondri- 
acal, and  manifestly  not  entirely  dependent  upon  masturbation;  for 
the  same  symptoms  are  very  common  in  patients  who  do  not  masturbate. 
As  to  atrophy  of  the  genitals,  varicocele,  etc.,  these  are  not  due  to 
masturbation.  Masturbation  is  a  symptom,  rather  than  a  cause,  of 
insanity. 

The  physical  damage  done  by  masturbation  (or  any  other  form  of 
sexual  excess)  is  confined  to  the  internal  genitals.  Its  most  patent 
expression  is  verumontanitis  (cf.  Hlihner  ^). 

The  foregoing  remarks  are  not  intended  to  palliate  in  the  least 
degree  the  baseness  of  the  practice  of  self-abuse,  or  to  deny  that  lack 
of  physical  and  sexual  vigor,  spermatorrhea,  neuralgia  of  the  urethra, 
etc.,  may  be  caused  by  its  excessive  indulgence ;  but  they  are  intended 
to  combat  the  prevalent  idea  that  very  few  men  indulge  in  the  secret 
vice,  and  that  all  who  do  so  suffer;  and  they  are  also  intended  to  ad- 
vance the  proposition  that  in  the  vast  majority  of  instances  masturba- 
tion does  little  harm  to  the  individual,  except  in  regard  to  his  morale. 
It  unmans  him,  makes  him  untrue  to  himself,  and  cowardly ;  and  most 
sensible  boys  find  this  out  before  a  great  while,  and  give  up  the  prac- 
tice, which  they  feel  to  be  sapping  their  manhood  and  self-esteem. 

Treatment — It  is  infinitely  better  that  a  boy  should  never  mastur- 

»iV.  r.  Med.  Jour.,  Feb.  17,  1912. 


MASTURBATION  633 

bate  if  he  can  be  prevented.  Prophylactic  instruction  may  save  him. 
No  instructor  can  equal  a  parent,  whose  moral  influence  outweighs  all 
consideration  of  amateurishness.  Every  child  has  a  right  to  know  the 
essentials  of  sexual  life.  Indeed  every  boy,  at  least,  will  learn  from 
an  evil  source  all  he  fails  to  learn  from  a  pure  one. 

The  parent's  chief  duties  are  two,  viz.,  to  answer  all  questions  with 
absolute  frankness  (for  they  are  asked  in  that  mood),  and  to  warn  the 
child  of  approaching  phenomena  of  emissions,  etc.,  as  well  as  of  the 
need  of  keeping  his  hands  off  his  own  genitals  and  those  of  others. 

In  the  case  of  babies  who  do  not  do  well,  nurses  should  be  watched 
and  discharged  if  they  are  found  handling  the  child.  If  the  infant 
has  already  acquired  the  habit,  his  hands  must  be  tied  when  he  sleeps, 
and  at  all  other  times  he  must  be  watched  until  he  grows  out  of  the 
habit.  Circumcision  often  helps  to  check  masturbation  whether  of  boy 
or  girl.  Boys  should  always  be  made  to  sleep  alone,  never  allowed  to 
consort  secretly  with  any  other  one  boy.  All  close  intimacies  between 
boys  of  different  ages  should  be  broken  up,  and,  on  the  appearance 
of  any  of  the  signs  of  masturbation,  a  close  watch  should  be  maintained. 

In  most  cases  it  is  not  good  policy  to  ask  a  boy  if  he  fingers  his 
privates.  He  will  be  pretty  sure  to  say  no,  and  then  to  tell  other  lies 
to  substantiate  the  first.  To  assume  the  fact  after  a  careful  study  of 
the  case  is  the  safest  course,  and  the  boy,  thrown  off  his  guard  by  the 
statement  that  he  does  masturbate,  will  rarely  deny  it,  or  will  do  so  in 
such  a  lame  manner  or  with  such  overpositiveness  as  to  convict  him- 
self. Finally,  when  the  patient  has  confessed  his  folly,  it  is  not  wise 
to  terrify  him  out  of  his  habit  by  brilliant  and  exaggerated  statements 
of  the  possible  misery  he  may  bring  upon  himself  if  he  does  not  desist. 
This  is  appealing  to  a  base  motive,  and,  although  sometimes  successful, 
it  is  often-  inadequate  to  the  proposed  end,  for  a  healthy  boy  cannot 
realize  what  it  means  to  be  sick ;  he  cannot  understand  it,  and  conse- 
quently is  not  afraid  of  it.  The  method  of  treatment  that  is  most 
effective,  but  requires  the  most  force  to  carry  out,  is  to  elevate  the  boy 
out  of  his  bad  habit,  to  shame  him,  to  make  a  man  of  him,  to  reason 
with  him,  and  to  talk  to  him  honestly  and  openly,  without  reserve  or 
mysticism. 

When  a  man  comes  complaining  of  the  results  of  masturbation,  an 
attentive  study  of  the  symptoms  will  prove  his  disease  to  be  hypochon- 
dria, and  his  malady  ungratified  sexual  desire,  often  with  congestion 
of  the  verumontanum.  His  training  should  consist  in  encouragement 
to  continence,  with  absolute  purity  of  thought,  and  subsequently  mar- 
riage, to  regulate  his  sexual  hygiene.  After  marriage  we  hear  no  fur- 
ther complaint  from  these  cases,  always  provided  there  is  really  nothing 
more  than  functional  derangement  at  the  bottom  of  the  patisnt's  com- 
plaint, as  is  the  case  in  the  vast  majority  of  instances. 


634  DERANGEMENTS  OF  THE  GENITAL  FUNCTION 

Treatment  of  tlie  inflamed  prostate  and  vesicles  by  massage  and  of 
the  verumontanum  by  instillations  or  nretliroscopic  applications  is  an 
essential  part  of  the  treatment  of  the  adult. 

Medicines  are  of  little  or  no  value;  camphor,  bromids,  or  lupulin 
may  be  given  as  placebos,  but  it  is  doubtful  if  they  have  any  efficacy. 
Cold  sponge-baths,  outdoor  sports,  physical  fatigiie,  sleeping  in  a  cool 
room  on  a  hard  bed  with  a  light  covering,  are  all  useful ;  eating  lightly 
at  night,  not  retiring  until  very  sleepy  and  rising  immediately  on  waking 
in  the  morning,  are  powerful  assistants  in  breaking  up  the  habit. 


POLLUTION 

Pollution  is  a  term  applied  to  involuntary  emissions  of  semen  in 
ejaculation,  attended  by  a  more  or  less  marked  venereal  orgasm.  Pol- 
lutions are  nocturnal  or  diurnal. 

NOCTURNAL  POLLUTIONS 

ISToctumal  pollutions  are  exceedingly  common.  They  usually  ac- 
company an  erotic  dream,  and  the  patient  wakes  just  as  the  ejaculation 
is  occurring.  When  sleep  is  profound,  the  patient  may  not  wake,  or, 
if  he  does,  he  forgets  his  dreams,  so  that  the  sensation  of  pleasure  accom- 
panying ejaculation  is  faint  and  forgotten.  Occasional  nocturnal  emis- 
sions are  entirely  natural  and  by  no  means  a  sign  of  disease.  Their 
frequency  compatible  with  health  varies  with  the  purity  of  mind  and 
the  sexual  vigor  of  the  patient.  A  man  who  is  happily  married  rarely 
has  nocturnal  emissions  while  living  with  his  wife,  but,  if  he  leaves 
her  for  several  weeks,  it  is  natural  that  there  should  be  a  formation  and 
•collection  of  semen  which,  distending  the  seminal  vesicles,  excites  erotic 
fancies  and  escapes  at  the  conclusion  of  a  dream.  Any  man  suffering 
from  ungratified  sexual  desire  is  normally  in  a  condition  demanding 
relief  for  his  overdistended  seminal  vesicles  and,  if  that  relief  be  not 
afforded  in  some  other  way,  it  comes  spontaneously  during  sleep.  This 
is  all  the  more  certain  to  be  the  case  if  he  has  established  a  habit  of  ex- 
cessive sexual  intercourse,  or  masturbation.  Occasionally  nocturnal 
emissions  may  be  overfrequent,  and  indicate  a  condition  of  irritation 
in  the  deep  urethra  which  requires  treatment. 

Treatment. — When  emissions  do  not  exceed  one  a  week  they  should 
be  disregarded,  and  attempts  made  only  to  purify  the  patient's  thoughts, 
to  elevate  his  physical  tone,  and  if  possible  to  get  him  happily  married. 
The  patient  should  exercise  and  develop  his  muscular  system.  He 
should  endeavor  to  tire  himself  out  by  physical  work  so  as  to  sleep 
soundly.     Locally,  cold  baths  and  cold  douches  are  useful.     He  sbouid 


PRIAPISM  635 

sleep  on  a  hard  bed,  lightly  covered.  The  stomach  should  not  be  full 
on  retiring.  Most  patients  have  involuntary  emissions  toward  morn- 
ing, and  waking,  find  themselves  lying  on  their  backs.  This  position, 
with  the  bladder  somewhat  distended,  tends  to  beget  erection,  and,  by 
avoiding  it,  pollution  may  be  escaped.  This  end  may  be  accomplished 
by  tying  a  towel  round  the  waist  on  retiring,  with  a  hard  knot  in  the 
back  of  the  spine.  When  the  patient  lies  upon  this  knot  it  awakens 
him. 

If  these  measures  fail,  or  if  the  ^.missions  recur  so  frequently  as 
really  to  do  harm,  local  treatment  for  vesiculitis,  prostatitis  or  veru- 
montanitis  is  required. 

From  time  to  time  different  mechanical  devices  appear  for  treat- 
ing pollution,  their  object  being  either  to  prevent  the  patient  from 
handling  himself  during  sleep  or  to  awaken  him  before  emission  when 
he  gets  an  erection.  I  believe  them  valueless  and  as  likely  to  do  harm 
as  good,  by  keeping  the  patient's  mind  concentrated  upon  his  malady 
and  leading  him  to  attach  too  much  importance  to  the  physical  act  of 
emission. 

DIUENAL  POLLUTION 

Diurnal  pollution  is  rare.  Some  impressionable  patients  acquire  so 
intense  a  prostatic  irritability  from  venereal  excess  that  the  sight  or 
thought  of  certain  women  or  the  lightest  friction  upon  the  glans  penis 
will  produce  ejaculation.  Such  injuries  to  the  spine  as  are  caused  by 
the  garrote  and  the  gallows  commonly  cause  ejaculation;  and  sexual 
perverts  find  in  shoes,  hats,  odors,  and  various  abominations  sufficient 
cause  for  pollution. 

PRIAPISM 

Priapism  is  a  condition  of  prolonged  erection  independent  of  the 
will  or  emotion  of  the  patient.  Such  erections  may  be  transitory,  in 
which  case  they  are  usually  due  to  some  local  inflammation  or  to 
cerebral  or  spinal  disease  (e.g.,  tabes).  But  in  severe  cases  the 
priapism  may  be  of  very  long  duration.  Hinman  ^  distinguishes  the 
cases  due  to  nervous  causes,  and  those  due  to  local  mechanical  causes. 
Among  the  former  3  were  due  to  peripheral  irritation  (phimosis,  fissure 
in  ano) ;  4  were  toxic,  3  due  to  cantharides  and  1  to  diabetes ;  5  due 
to  nasal  polypi  and  cured  by  their  removal,  13  to  fracture  of  the  spine, 
1  to  myelitis,  and  another  to  tumor  of  the  spinal  cord. 

Among  the  cases  due  to  mechanical  cause,  64  followed  sexual  excess 
and  in  55  of  these  there  was  thrombosis  of  the  corpora  cavernosa,  6  other 
cases  of  thrombosis  followed  a  systemic  infection,  in  2  cases  there  was 

'^Annals  of  Surgery,  December,  1914. 


636  DERANGEMENTS  OF  THE  GENITAL  FUNCTION 

infiltration  with  neoplasm,  while  2  others  were  attributed  to  angio- 
neurosis.  Injury  produced  the  thrombosis  in  7  cases ;  ''45  cases  showed 
a  definite  relationship  to  leukemia." 

Hinman  states  that  priapism  is  most  common  between  the  twentieth 
and  the  fiftieth  years,  and  that  it  may  continue  for  from  a  few  hours 
to  two  years.  The  nervous  cases  of  functional  origin  are  usually  repe- 
titious and  brief.  Pain  may  be  absent  or  severe.  There  may  be  some 
disturbance  of  urination ;  sexual  desire  is  usually  absent.  Many  of  the 
cases  have  gotten  well  spontaneously  or  by  treatment  of  a  recognized 
etiological  factor.  Hinman  suggests  operative  relief  by  division  or  in- 
jection of  the  internal  pudic  nerve,  by  ligation  of  the  dorsal  arteries, 
or  by  dividing  the  ischiocavernosi  muscles.  Tor  priapism  due  to  throm- 
bosis of  the  corpora  cavernosa  incision  has  been  employed  with  success 
in  31  out  of  33  cases.  Hinman  suggests  that  incision  in  one  corpus  is 
likely  to  drain  both,  since  the  vascular  anastomosis  is  free. 


CHAPTEK  LXVI 


DISEASES    OF    THE   PENIS— ANATOMY— ANOMALIES- 
INFLAMMATIONS 


-INJURIES- 


ANATOMY 


The  penis  is  a  genital  organ.  Its  urinary  function  is  purely  sec- 
ondary. It  is  conformed  anatomically  to  subserve  the  genital  function. 
In  the  adult  it  measures,  when  at  rest,  from  the  root  of  the  scrotum 
to  the  meatus  urinarius,  from  6  to  10  cm.  (2^  to  4  inches)  ;  when  erect, 
from  12  to  17  cm.  (5  to  7  inches).  It 
consists  essentially  of  three  segments — ^the 
two  corpora  cavernosa,  lying  together  like 
the  barrels  of  a  gun,  and  the  corpus  spon- 
giosum, like  the  ramrod,  beneath  them 
(Fig.  133),  the  whole  surrounded  by  in- 
tegTiment. 

The  Corpora  Cavernosa. — The  corpora 
cavernosa  arise  on  each  side  from  the 
tuberosities  and  ascending  rami  of  the 
ischium.  They  come  together  under  the 
symphysis  pubis,  and  continue  side  by 
side,  forming  the  main  bulk  of  the  penis. 
They  terminate  anteriorly  in  a  conical  ex- 
tremity, over  which  the  glans  penis  (the 
terminal  expansion  of  the  corpus  spongio- 
sum) fits  like  a  cap.  There  is  no  vascular 
communication  between  the  corpora  caver- 
nosa and  the  glans  penis,  or  the  corpus 
spongiosum. 

The  corpora  cavernosa  are  surrounded 
by  fibrous  sheaths  which  are  so  dense  and 
strong  that  they  will  support  the  weight  of 
the  cadaver.^  These  sheaths  are  plenti- 
fully supplied  with  elastic  fibers.  The  an- 
terior portion  of  the  partition  between  the  corpora  cavernosa  is  per- 
forated by  numerous  apertures,  to  insure  symmetrical  erection.     The 

* Cruveilhier,  " Traite  d'anatomie  descriptive,"  Paris,  1865,  ii,  I,  388. 

637 


Fig.  133. — Transverse  Sections 
OF  Penis  (Cruveilhier).  A, 
flaccid.  B,  in  erection.  1,  2, 
dorsal  vein  and  artery;  3,  cor- 
pora cavernosa;  4,  tunica  al- 
buginea;  5,  integument;  6,  tun- 
ica albuginea  of  corpus  spon- 
giosum; 7,  erectile  tissue;  8, 
urethra. 


638  DISEASES  OF  THE  PENIS 

tissue  proper  of  tlie  corpora  cavernosa  consists  of  large  venous  spaces, 
known  as  spongy  or  erectile. 

The  Corpus  Spongiosum. — The  corpus  spongiosum  urethrae  is  also 
composed  of  erectile  tissue.  It  surrounds  all  that  portion  of  the  urethra 
lying  in  front  of  the  triang-ular  ligament,  anteriorly  forming  the  glans 
penis,  which  caps  the  conical  extremity  of  the  corpora  cavernosa,  pos- 
teriorly terminating  in  the  bulb,  which  lies  just  in  front  of  the  triang-u- 
lar ligament  in  the  angle  of  the  converging  corpora  cavernosa  and 
below  the  urethra. 

The  Glans. — The  glans  penis  (Fig.  13)  is  covered  by  a  semimucous 
membrane  endowed  with  peculiar  sensibility,  especially  around  the 
raised  posterior  border — the  corona  giandis.  The  epithelium  covering 
the  glans  is  fine,  the  papillae  minute,  the  sebaceous  glands  (of  Tyson) 
large  and  numerous,  and  most  plentiful  about  the  f renum.  These  glands 
secrete  the  white  material  (smegTaa)  that  collects  behind  the  corona. 
The  function  of  the  glans  penis  is  to  furnish  a  soft-skinned  expansion 
for  the  distribution  of  the  terminal  filaments  of  the  nerv^es  of  sexual 
sensibility. 

Muscular  Action — One  important  function  of  the  corpus  spon- 
giosum is  acquired  through  its  bulb — namely,  that  of  assisting  in  the 
expulsion  of  the  last  drops  of  urine  or  semen  from  the  urethra.  The 
prostate,  the  levator  ani,  and  the  deep  urethral  muscles — especially  the 
compressor  urethrae- — contract  upon  the  fluid  remaining  in  the  canal 
after  micturition  in  a  spasmodic  "piston-stroke."  This  forces  the  last 
few  drops  beyond  the  bulb  of  the  urethra.  ISTow  the  fibers  of  the  accel- 
erator urinae  surrounding  the  bulb  and  adjacent  portions  of  the  corpus 
cavernosum  contract,  and  drive  the  blood  contained  in  the  areolae  of 
the  bulb  forward  along  the  corpus  spongiosum,  distending  that  body, 
and  thus  bringing  the  walls  of  the  urethra  more  closely  into  contact  in  a 
progressive  wave.  If  there  is  organic  stricture  the  last  few  drops  of 
urine  do  not  escape  promptly,  but  dribble  away;  for  the  scar  tissue 
which  constitutes  stricture  obliterates  the  areolae  of  the  erectile  tissue 
and  thus  obstructs  the  free  passage  of  the  wave  of  blood  along  the  corpus 
spongiosum. 

Fascia. — The  three  erectile  bodies  which  have  been  briefly  described 
are  surrounded  by  the  fascial  sheath  of  the  penis.  This  fascia  (called 
Buck's  fascia)  arises  from  the  symphysis  pubis  by  a  triangular  bundle 
of  fibers,  the  suspensory  ligament  of  the  penis,  and  from  the  pubic  rami 
at  the  attachment  of  the  anterior  layer  of  the  triang-ular  ligament. 
Thence  it  runs  forward,  surrounding  the  corpora  cavernosa  and  the 
corpus  spongiosum  in  two  separate  compartments.  The  lower  plane  of 
this  fascia  is  in  its  posterior  part  identical  with  the  deep  layer  of  the 
perineal  fascia.  The  cavity  of  Buck's  fascia  is  bounded  anteriorly  by 
the  base  of  the  glans  penis  and  posteriorly  by  the  triangular  ligament. 


ANOMALIES  OF  THE  PENIS  639 

Hence  peri-urethral  cellulitis  and  extravasation  are  habitually  confined 
within  these  limits  for  an  indefinite  time,  unless  at  the  root  of  the  penis 
where  the  fascia  blends  with  that  covering  the  pubes,  and  leaves  a  loop- 
hole of  escape  into  the  subcutaneous  tissue  of  the  abdominal  wall. 

Vessels. — The  lymphatics  and  veins  of  the  penis  run  along  the 
dorsum,  and  receive  in  their  course  branches  from  the  corpus  spon- 
giosum. The  lymphatics  lead  mainly  to  glands  lying  along  and  above 
Poupart's  ligament  on  each  side.  The  arteries  arise  from  the  internal 
pudics. 

Connective  Tissue. — The  connective  tissue  between  the  skin  and 
Buck's  fascia  is  very  loose  and  elastic,  and,  like  that  of  the  eyelids, 
does  not  contain  fat. 

Skin — The  skin  of  the  penis,  except  that  it  tends  to  become  pig- 
mented after  puberty,  does  not  differ  essentially  from  ordinary  in- 
tegument. Over  the  glans  penis  it  folds  back  upon  itself,  forming  a 
nonadherent  sheath  for  the  glans  (the  prepuce),  evidently  intended  to 
preserve  the  delicate  sensibility  of  this  portion  of  the  member. 

The  Prepuce. — The  prepuce  is  composed  of  two  layers,  a  cutane- 
ous (external)  and  a  more  delicate  semimucous  (internal).  The  point 
of  junction  of  these  two  is  called  the  orifice  of  the  prepuce.  Between 
these  layers  is  a  very  loose  and  elastic  connective  tissue,  without  fat, 
which  permits  the  two  surfaces  to  be  entirely  separated  from  each  other, 
and  the  prepuce  effaced,  by  drawing  back  the  integiiment  of  the  penis 
until  the  glans  is  entirely  uncovered.  The  mucous  layer  of  the  prepuce 
is  supplied  with  glands  (of  Tyson).  It  is  much  less  elastic  than  the 
cutaneous  layer. 

The  prepuce  is  attached  to  the  lower  angle  of  the  meatus  urinarius 
by  a  triangular  fold  of  mucous  membrane  called  the  frenum  preputii — 
analogous  to, the  frenum  linguae.     The  frenum  contains  a  small  artery. 


ANOMALIES  OF  THE  PENIS 

Deformities  of  the  urethra  are  described  on  p.  543. 

Double  Penis. — Double  penis  is  excessively  rare.  It  is  analogous  to 
double  uterus  and  vagina  in  the  female,  but  by  no  means  so  common.  Un- 
doubtedly it  is  not  so  rare  as  the  records  of  surgery  imply,  for  the  exist- 
ence of  this  deformity  naturally  leads  the  patient  to  shun  observation; 
and,  as  the  defect  is  not  necessarily  accompanied  by  any  injurious  symp- 
toms, he  does  not  voluntarily  subject  himself  to  the  inspection  of  a  physi- 
cian. Hence  the  cases  usually  reported,  such  as  those  of  Ilart^  andGorre,^ 
accompany  grosser  malformations  of  fetal  inclusion.    The  case  reported 

^Lancet,  1866,  i,  71.  'Compt.  rend,  de  I' Acad,  des  Sciences,  1844. 


640  DISEASES  OE  THE  PENIS 

in  the  first  edition  of  this  treatise  ^  is  a  notable  exception.  Similar  ones 
are  reported  bj  Drs.  Alan  P.  Smith,-  J.  Lorthior,^  and  Carl  Beck.* 

Smith's  patient  had  a  stone  in  one  of  his  bladders,  was  cut  and 
cured.     He  could  urinate  from  either  bladder  at  will. 

Torsion  of  the  Penis. — With  epispadias  and  hypospadias  the  penis 
may  be  more  or  less  completely  twisted  upon  itself.  Jacobson^  has 
collected  a  number  of  cases.  In  Caddy's  ^  case  the  torsion  was  unaccom- 
panied by  any  urethral  defect. 

Absence  of  Penis — The  various  amputations  of  the  penis,  surgical, 
traumatic,  or  gangrenous,  do  not  concern  us  here.  The  congenital  de- 
formity is  a  rare  one,  and  usually  unaccompanied  by  any  faulty  devel- 
opment of  the  testicles  or  of  other  parts  of  the  body.  The  scrotum,  how- 
ever, is  usually  small  and  may  be  bifid.  In  either  case  the  external 
genitals  closely  resemble  those  of  a  woman.  This  is  male  pseudoher- 
maphroditism. The  line  of  pubic  hair  is  said  to  be  an  infallible  sign 
of  the  sex  of  such  a  person  if  an  adult.  If  a  female,  the  upper  border 
of  the  hair  forms  a  transverse  line  across  the  hypogastrium,  while  the 
hair  of  the  male  rises  up  in  a  curved  line  toward  the  umbilicus. 

The  urethra  opens  in  the  median  perineal  raphe  or  on  the  anterior 
rectal  wall.  In  the  latter  case  there  is  danger  of  ascending  infection 
(Matthews''').  Harris^  collected  6  cases,  including  1  of  his  own, 
omitting  2,  Kevolat's  ^  and  Wright's.^^  More  recently  Preston  ^^  has 
reported  a  case. 

Apparent  Absence  of  Penis — Congenital  dislocation  or  apparent 
absence  of  the  penis  exists  when  the  penis,  lacking  its  proper  sheath  of 
skin,  lies  buried  beneath  the  integ-ument  of  the  abdomen,  thigh,  or 
scrotum.  Boutelier  ^-  reports  such  a  case.  Under  the  skin  above  the 
scrotum  a  movable  body  was  felt,  liberated  by  incision,  and  discovered 
to  be  the  penis.  Another  case,  reported  by  J.  Murphy,^  ^  would  seem  to 
be  rather  a  penile  adhesion  to  the  hypogastrium,  for  the  child  could 
urinate  through  a  hole  in  the  lower  part  of  the  abdomen.  The  treat- 
ment of  such  a  condition  implies  the  immediate  liberation  of  the  incar- 

^  Case  I,  Van  Buren  and  Keyes. 

^  Trans  Med.  and  Chir.,  Facnilty  of  Maryland,  April,  1878. 

^Centralbl.  f.  d.  Erankh.  d.  Ham.  u.  Sex.  Org.,  1901,  xii,  381. 

*  Med.  News,  1901,  Ixxix,  451. 

*" Diseases  of  the  Male  Organs  of  Generation,"  1892,  p.  612. 

''Lancet,   1894,  ii,  634. 

''  Phila.  Med.  Jour.,  1898,  i,  71. 

'^  Amer.  Practitioner  and  Netvs,  1894,  xvii,  27. 

®  J.  de  SediUot,  xxvii,  370;  Demarquay,  Maladies  chir.  du  yenis,  Paris,  1879^  p. 


538. 


'Ashby  and  Wright,  "Diseases  of  Children,"  p.  531. 
'Med.  Record,  1898,  liv,  315. 
'  Union  med.  de  la  Seine  infer.,  1875,  xi,  27. 
'Brit.  Med.  Jour.,  1885,  ii,  62. 


ACCIDENTS  TO  THE  PENIS  AS  A  WHOLE  641 

cerated  member  to  avoid  urinary  infiltration.  In  this  emergency  any 
method  of  covering  the  denuded  penis  v^ith  skin  may  be  employed,  the 
simpler  the  better,  leaving  until  later  years  the  task  of  affording  a  more 
satisfactory  envelope  to  the  organ. 

Congenital  incurvation  of  the  ijenis  and  scrotal  concealment  of  that 
organ  occur  as  phenomena  accessory  to  hypospadias,  and  will  be  consid- 
ered as  such. 

Hermaphroditism.! — Accepting  Klebs's  definition  of  true  hermaph- 
roditism— viz.,  the  existence  of  dissimilar  genital  glands  (i.  e.,  at  least 
one  testis  and  one  ovary)  in  one  individual — there  is  still  some  doubt 
vi^hether  any  such  individual  has  existed.  Dr.  Blacker  and  Mr.  Law- 
rence -  maintain  the  positive  side  of  the  question,  and  find  in  the  litera- 
ture foundation  for  their  belief.  In  no  case  has  it  been  recorded  that 
the  person  was,  functionally,  both  male  and  female,  producing  both 
spermatozoa  and  ova.  On  the  contrary,  as  a  general  rule  they  are  sexu- 
ally neuter.  These  true  hermaphrodites  resemble  clinically  the  pseudo- 
hermaphrodites— persons  whose  sex  can  with  difficulty  be  determined — • 
and  they  sometimes  come  to  the  surgeon  asking  him  to  make  them  dis- 
tinctively male  or  female,  whichever  he  may  deem  more  appropriate. 
In  deciding  such  a  question,  if  the  external  genitals  are  quite  indeter- 
minate— as  they  often  are — the  chief  characteristics  to  be  considered 
are  the  shape  of  skeleton,  the  disposition  of  the  superficial  fat,  the 
gTowth  of  hair,  facial  and  pubic  (see  above),  the  voice  and  the  shape 
of  the  larynx,  and,  finally,  the  sexual  sentiments  of  the  individual.  The 
process  of  '^'making  a  man  of  him"  or  "a  woman  of  her"  may  be  long 
and  tedious,  but  may  prove  successful,  as  in  a  case  reported  by  Gruber,^ 
in  which  amputation  of  the  hypertrophied  clitoris,  posterior  colpotomy 
to  enlarge  the  rudimentary  vagina,  and  electric  epilation  of  the  facial 
hair  sufficed  to  establish  the  external  female  characteristics. 


ACCIDENTS  TO  THE  PENIS  AS  A  WHOLE 

Wounds — The  penis  is  liable  to  be  wounded  by  accident  or  by  de- 
sign. In  the  latter  case  insanity,  or  the  melancholy  depression  pro- 
duced by  masturbation,  induces  the  patient  to  mutilate  himself;  or  the 
injury  may  be  inflicted  by  a  jealous  woman. 

Superficial  cuts  are  unimportant,  but  wounds  extending  through  the 
sheaths  of  the  corpora  cavernosa  may  give  rise  to  troublesome,  possibly 
fatal,  hemorrhage,  while  the  cicatrices  left  after  healing  may  distort  the 
penis  and  render  erection  imperfect  and  painful. 

'Cf.  Hart,  Edinb.  Med.  Jour.,  1914,  xiii,  295. 
^  Trans.  Obstet.  Sac,  Lond.,  1896,  xxxviii,  265. 
•  Ceniralhl.  f.  d.  ges,  Therap.,  Wien,  1897,  xv,  385. 


642  DISEASES  OF  THE  PENIS 

Treatment. — Cleanse  the  wound.  Endeavor  to  obtain  primary 
union  by  immediate  suture.  Introduce  the  sutures  just  deep  enough  to 
bold  the  fibrous  sheath.  Employ  moderate  pressure  in  dressing.  Erec- 
tions, which  are  sure  to  occur,  since  the  local  inflammation  induces  a 
flux  of  blood,  retard  healing. 

Even  in  cases  seemingly  desperate,  where  the  penis  has  been  almost 
wholly  severed  from  the  body,  an  attempt  should  be  made  to  save  it.  A 
remarkable  success  in  a  case  of  this  sort,  where  the  whole  penis  was 
severed  except  a  portion  of  one  corpus  cavernosum,  is  related  by  Ar- 
taud.^     Erectile  power  is  not  regained  after  such  a  recovery. 

Contusions. — The  escape  of  blood  under  the  skin  after  superficial 
contusions  of  the  penis  is  often  excessive,  on  account  of  the  laxity  of 
the  connective  tissue  and  the  large  size  of  the  superficial  veins.  Deeper 
contusions  give  rise  to  localized  swelling  from  circumscribed  effusion 
of  blood.  This  swelling  fluctuates  and  deforms  the  penis  more  or  less, 
sometimes  causing  it  to  deviate  when  erect.  Inflammation  of  the  cor- 
pora cavernosa  may  result,  terminating  in  suppuration  or  gangrene. 
Severe  contusions  involving  the  urethra  may  lead  to  inflltration  of  urine 
and  urethral  fistula. 

The  introduction  of  the  penis  into  a  ring  is  a  classical  accident.  The 
penis  swells,  the  patient  is  ashamed  to  seek  relief,  and  serious  inflam- 
matory mischief — even  gangrene,  urinary  fistula — ^may  ensue.  Guillot 
in  such  a  case  conceived  the  happy,  idea  of  dissolving  the  ring,  which 
was  of  gold,  in  a  bath  of  mercury.  Demarquay  ^  narrates  many  curi- 
ous instances  of  a  similar  character. 

Subcutaneous  hemorrhage  may  be  controlled  by  the  application  of 
cold  and  pressure,  with  due  regard  for  the  possibility  of  sloughing  if 
the  treatment  is  overdone.  Later,  simple  pressure  to  promote  absorp- 
tion will  suffice,  or  the  clots  may  be  evacuated  through  an  incision  made 
under  local  anesthesia  with  the  usual  aseptic  precautions.  If  gangrene 
occur,  the  penis  should  be  kept  absolutely  dry  and  clean  by  applying  a 
mildly  antiseptic  powder  and  a  gauze  dressing.  The  gangrenous  tissue 
may  be  removed  piecemeal,  after  which  the  gaps  may  be  filled  in  by 
skin-grafting  or  by  a  plastic  operation. 

Injuries  involving  the  urethra  are  described  on  p.  524. 
Fracture  of  the  Penis — When  the  fibrous  sheaths  of  the  corpora 
cavernosa  are  ruptured  by  sudden  forcible  flexion  of  the  erect  penis, 
a  sort  of  fracture  of  the  member  is  produced,  with  extensive  extravasa- 
tion of  blood,  sometimes  amounting  to  traumatic  aneurysm.  .  Valen- 
tine Mott  ■'  reported  two  interesting  cases  of  this  accident,  where  the 
only  treatment  employed  was  rest  and  cold  locally  applied.     Both  re- 

^  Bull,  de  la  Sac.  dc  CJiir.,  vii,  p.  451. 

*"  Maladies  cliir.  du   penis,"  Paris,    1877. 

*  Trans,  of  the  N.  Y.  Acad,  of  Med.,  vol.  1,  Part  I,  1851,  p.  99. 


ACCIDENTS  TO  THE  PENIS  AS  A  WHOLE  643 

covered  with  a  useful  organ  and  no  deformity.  Demarquay  has  cited 
many  others. 

TREATMENT. — A  Catheter  is  passed  into  the  bladder  to  insure  the 
patulousness  of  the  urethra.  Upon  this  the  penis  is  bandaged  and  an  ice 
cap  applied.  If  the  pressure  proves  unbearable  or  if  gangrene,  ex- 
travasation, or  cellulitis  threaten,  the  clots  must  be  evacuated  and  the 
bleeding  checked  by  suture.  The  urine  should  be  diverted  through  a 
hypogastric  opening. 

After  recovery  an  indurated  spot  may  remain  permanently  to  mark 
the  site  of  the  injury,  perhaps  resulting  in  priapism  or  stricture. 

Fracture  of  Corpus  Spongiosum. — Fracture  of  the  corpus  spongi- 
osum is  generally  occasioned  by  "breaking  the  chordee"  in  gonorrhea. 
The  inflamed  tissue  gives  way,  yielding  urethral  hemorrhage  as  an 
immediate  and  traumatic  stricture  as  a  remote  result. 

The  healthy  corpus  spongiosum  may  be  fractured  during  erection. 
Dittel  ^  gives  one  such  case.     My  father  has  seen  another.^ 

Dislocation  of  the  Penis. — ^When  the  integument  of  the  penis  is 
violently  dragged  upon,  as,  for  instance,  when  the  clothes  are  caught 
and  torn  away  upon  a  revolving  wheel,  the  entire  penis  may  be  shot  out 
of  its  investing  cutaneous  sheath  and  lodged  in  the  scrotum,  the  peri- 
neum, the  groin,  or  under  the  integument  of  the  abdomen.  In  such 
cases,  the  semimucous  membrane  of  the  prepuce  gives  way  either  at  the 
preputial  orifice  or  just  behind  the  corona.  A  number  of  instances  of 
this  curious  luxation  have  been  recorded.^  The  penile  injury  is  usually 
not  discovered  until  retention  of  urine  or  the  passage  of  urine  by  some 
opening  at  a  distance  from  the  preputial  orifice  directs  attention  to  the 
contused  genitals,  when  the  penis  is  found  to  be  only  a  sheath  of  in- 
tegument containing  clotted  blood.  Sometimes  it  has  been  difficult  to 
find  the  pCnis  at  all ;  but  an  intelligent  search  will  always  reveal  it,  and 
then  the  surgeon's  obvious  duty  is  to  replace  it  in  its  sheath,  incising  the 
integument  about  its  root  as  far  as  may  be  necessary  to  attain  the  de- 
sired result. 

In  dislocation,  the  urethra  is  often  ruptured  low  down,  and,  after 
the  organ  has  been  replaced  in  its  sheath,  operation  for  urethral  rupture 
may  be  called  for. 

In  one  case,  a  six-year-old  child,  Nelaton  reduced  a  dislocated  penis 
through  the  preputial  orifice  by  means  of  an  aneurysm  needle,  assisting 
its  hook  action  by  external  manipulation. 

^  Wien.  med.  Blatter,  1885,  Nr.  2, 
^  Van  Buren  and  Keyes,  1st  ed.,  p.  7. 
« Cf.  Goldsmith,  Lancet,  1898,  ii,  387. 


644  DISEASES  OF  THE  PENIS 

CUTANEOUS  AND  MUCOCUTANEOUS  AFFECTIONS  OF  THE 

PENIS 

Many  common  skin  diseases  involve  tlie  skin  of  the  penis  as  well  as 
other  integumentary  parts.  As  a  rule,  tliey  present  no  special  charac- 
teristics and  require  no  comment  here.  Venereal  sores,  true  chancre 
and  chancroid,  are  common,  as  also  are  soft  venereal  warts.  These  re- 
ceive mention  elsewhere.  Hutchinson  ^  circumcised  a  boy  for  lupus 
of  the  prepuce  and  obtained  a  perfect  result.  Rake,  of  Trinidad,^  has 
performed  circumcision  on  16  lepers,  and,  even  though  the  incision 
actually  traversed  a  leprous  patch,  it  always  healed  kindly. 

Scabies. — Sometimes  scabies  produces  papular,  crusted  and  con- 
fluent lesions  on  the  glans  or  skin  of  the  penis,  closely  resembling  the 
venereal  sores.  The  lesion  is  crusted  rather  than  ulcerative,  typical 
burrows  may  be  found,  and  the  eifect  of  sulphur  ointment  is  magical. 

Herpes  Progenitalis. — This  affection  consists  in  the  development 
of  clusters  of  vesicles  upon  reddened  patches  on  the  mucous  covering  of 
the  glans,  or  on  either  layer  of  the  prepuce,  or  on  other  portions  of  the 
neighboring  skin,  attended  by  a  slight  sensation  of  heat  and  tingling. 
When  occurring  on  the  cuticular  layer,  herpes  runs  its  course  as  it  does 
elsewhere  on  the  body,  but  when  vesicles  develop  within  the  preputial 
orifice  the  epithelium  of  the  vesicles  is  soaked  off,  little  ulcerations  re- 
sult, more  or  less  general  inflammation  is  likely  to  arise  from  retention 
of  the  secretions,  and  balanitis,  with  posthitis,  vegetations,  and  inflam- 
matory phimosis,  may  be  the  ultimate  result.  Exceptionally  the  ulcera- 
tions become  deep  and  angry,  and  the  diag-nosis  from  chancroid  difficult, 
while  the  glands  in  the  groin  may  inflame  and  suppurate. 

The  affection  shows  a  marked  tendency  to  recur.  A  tight  prepuce 
and  contact  of  irritating  discharges  act  as  predisposing  causes. 

Diagnosis. — Vesicles,  usually  in  groups,  always  precede  the  ulcera- 
tions, while  the  latter  are  irregailar  in  shape,  superficial,  and  very  rarely 
complicated  by  suppurating  bubo.     The  pus  is  not  auto-inoculable. 

Treatment. — Until  the  vesicles  break  there  is  no  treatment.  There- 
after the  ulcers  should  be  dusted  with  any  mild  antiseptic  powder. 
Recurrence  may  sometimes  be  prevented  by  circumcision;  but  often  it 
cannot  be  prevented. 

Herpes  Zoster. — Zoster  may  occur  upon  the  penis  as  elsewhere. 

Lichen  Planus.  — This  occurs  on  the  glans  penis,  simulating  almost 
precisely  a  squamous  syphilid.  They  may  be  distinguished  by  the 
Wassermann  reaction  and  by  biopsy.  Elliott  states  that  the  syphilitic 
eruption  is  never  wholly  confined  to  the  glans. 

^Arch.  of  Surg.,  1890,  ii,  17. 

'St.  Louis  Med.  and  Surg.  Jour.,  1893,  Ixiv,  221. 


CUTANEOUS  AND  MUCOCUTANEOUS  AFFECTIONS  645 

Balanoposthitis. — Balanitis  ( /^aXavos,  a  gland)  is  an  inflamma- 
tion of  the  surface  of  the  glans  penis.  Posthitis  (  tto'o-^ij^  the  prepuce) 
is  an  inflammation  affecting  the  mucous  surface  of  the  piepuce  chiefly. 
Neither  can  exist  for  any  length  of  time  without  becoming  more  or  less 
complicated  by  the  other.  For  practical  purposes  they  must  be  consid- 
ered together. 

Etiology. — Persons  of  irritable  skin  and  gouty  habit  are  predis' 
posed  to  this  disorder.  A  long  and  tight  prepuce  is  always  a  predis- 
posing cause.  The  exciting  causes  are  mechanical  irritation  or  unclean- 
liness  from  retention  of  smegma,  or  from  contact  with  diabetic  urine, 
gonorrheal,  leukorrheal,  menstrual,  or  other  irritating  fluids. 

Symptoms. — The  membrane  at  first  becomes  reddened,  then  mottled 
and  moist;  next  the  epithelium  comes  off  in  patches,  leaving  irregular 
excoriations  which  soon  ulcerate  and  discharge  a  purulent  fluid.  The 
ulcerations  are  not  preceded  by  vesicles.  There  is  a  burning  soreness 
with  itching  at  the  end  of  the  penis,  usually  scalding  on  urination.  The 
entire  prepuce  may  inflame,  become  red  and  infiltrated,  producing  in- 
flammatory phimosis.  The  ulcerations  rarely  become  deep,  and  the 
inguinal  glands  do  not  often  suppurate,  but  they  may  grow  somewhat 
large  and  tender.  In  chronic  balanitis  with  phimosis,  the  mucous  sur- 
face of  the  prepuce  is  gTanular  and  even  condylomatous. 

R.  W.  Taylor  ^  has  described  a  peculiar  ringed  affection  of  the  pre- 
puce and  glans — narrow  rings  of  reddened  mucous  membrane  covered 
by  a  thin  layer  of  epithelial  scales.  The  inclosed  area  is  normal,  the 
rings  vary  from  ^  to  |-  inch  in  diameter.  The  affection  is  sometimes 
painful  or  itching.  The  rings  remain  stationary  for  a  time.  They  may 
come  out  in  successive  crops.  They  get  well  without  scar,  slowly,  under 
the  use  of  arsenic  internally.  They  should  not  be  confounded  with 
lichen  planus  of  the  glans  penis. 

Diabetic  halaiio posthitis  is  caused  by  contact  of  the  saccharine 
urine. 

Erosive  and  gangrenous  balanitis  "  is  a  specific  infection  caused  by 
a  spirocheta  and  a  bacillus  quite  similar  to  those  found  in  Vincent's 
angina.  The  infection,  if  mild,  results  in  superficial  erosions  about 
the  corona  or  the  adjacent  portions  of  the  prepuce,  rarely  on  the  glans 
penis.  This  infection  may  lead  to  ulceration,  cellulitis  of  the  prepuce, 
and  even  to  gangrenous  ulceration  with  perforation  of  the  prepuce. 

Erosive  meatitis  of  little  boys  is  a  circumscribed  lesion  about  the 
meatus  described  by  Goldenberg.^  It  lasts  a  few  months  and  heals 
spontaneously.  The  scab  may  close  the  meatus.  Any  mild  ointment 
will  prevent  this. 

^  Arch,  of  Med.,  1884,  vol.  xii,  No.  3. 

=  Cf.  Corbus  and  Harris,  Jour.  A.  M.  A.,  1909,  lii,  1474. 

^  Am.  Jour.  Surg.,  1910,  xxiv,  218. 


646  DISEASES  OF  THE  PENIS 

Adhesions  due  to  balanitis  are  uncommon  after  early  childliood.  In 
elderly  persons  tlie  possibility  of  epitheliomatous  degeneration  in  a 
patch  of  chronic  balanitis  must  be  borne  in  mind. 

DiAGiYOsis. — Balanitis  occurs  only  under  a  long  or  a  tight  prepuce. 
Simple  balanitis  must  be  distinguished  by  urinalysis  from  diabetic 
balanitis. 

Ulcerative  balanitis  cannot  be  distingiiished  from  inflamed  herpes 
in  many  cases.  It  also  closely  resembles  chancroid,  from  which  it  can 
often  only  be  distinguished  bj^  examination  of  the  organisms  found  in 
the  satellite  glands.  Fortunately  the  treatment  of  severe  cases  of  the 
three  conditions  is  the  same. 

Treatment. — If  the  prepuce  can  be  easily  retracted  without  caus- 
ing paraphimosis,  simple  balanitis  may  be  speedily  relieved.  Cleanli- 
ness is  of  the  first  importance,  but  soap  should  not  be  used.  Warm 
water  and  peroxid,  aa,  will  remove  all  the  discharges.  After  washing, 
the  parts  should  be  dried  by  gently  touching  them  with  a  soft  cloth, 
and  dusted  (by  the  aid  of  a  dry  camel's-hair  brush  from  which  the 
powder  may  be  evenly  shaken)  with  bismuth  and  calomel,  or  any  fine 
powder.  A  piece  of  old  linen,  just  large  enough  to  cover  the  glans, 
and  with  a  hole  cut  in  its  center  so  that  it  may  be  slipped  like  a  collar 
around  the  corona,  is  now  to  be  moistened  in  a  mild  antiseptic  solution 
(acetate  of  aluminum  2  per  cent,  or  aromatic  wine  and  water,  equal 
parts)  and  laid  over  the  glans,  leaving  the  meatus  uncovered.  The 
prepuce  is  then  pulled  forward  to  its  natural  position.  In  this  way 
friction  between  the  inflamed  surfaces  is  avoided,  all  the  discharges 
are  absorbed,  and  a  mildly  stimulating  fluid  is  kept  in  constant  contact 
with  the  ulcerated  or  abraded  surfaces.  The  dressing  should  be  re- 
peated two  to  four  times  daily,  according  to  the  discharge.  After 
recovery  a  dry  piece  of  linen  should  be  kept  between  the  glans  and  the 
prepuce  for  some  weeks,  renewed  twice  daily.  Argyrol,  sol.  saturat.,  is 
an  almost  infallible  application.  It  should  be  employed  in  all  severe 
cases. 

If  the  prepuce  cannot  be  retracted,  it  should  be  incised,  as  for  chan- 
croid, and  sores  and  wounds  bathed  lavishly  in  20  per  cent  argyrol  solu- 
tion. 

If  chancroid  be  present,  inoculation  of  the  wound  is  inevitable. 
Yet  chancroidal  cases  require  operation  most  urgently  in  order  to 
expose  the  sore,  whose  ravages  (perhaps  upon  the  glans  penis)  are 
progressing  uncontrolled.  A  large  chancroid  exposed  is  better  than  a 
small  one  concealed. 

Circumcision. — In  chronic  and  inveterate  cases,  or  where  insignifi- 
cant causes  produce  constant  relapse,  circumcision  affords  a  certain 
cure.  Circumcision  of  diabetics,  while  almost  certain  to  prove  curative, 
may  result  in  gangrene. 


ACUTE  INFLAMMATORY  AFFECTIONS  647 


ACUTE  INFLAMMATORY  AFFECTIONS  OF  THE  PENIS 

Cellulitis. — Cellulitis  arises  from  chancroids,  balanoposthitis, 
trauma,  or  gonorrheal  peri-urethritis.  The  inflammation  may  spread 
to  the  abdomen,  scrotum,  or  thighs,  or  it  may  involve  the  erectile  bodies. 

Lymphangitis — Lymphangitis  is  comparatively  benign.  A  lym- 
phangitis of  the  large  dorsal  lymphatic  may  be  differentiated  from 
phlebitis  of  the  dorsal  vein  by  the  fact  that  the  cord  of  induration  ex- 
tends outward,  at  the  root  of  the  penis,  toward  a  group  of  enlarged 
glands,  instead  of  disappearing  beneath  the  symphysis  pubis. 

Erysipelas. — Erysipelas  of  the  penis  is  rare.  It  usually  spreads 
to  the  penis  from  the  adjoining  regions.  It  is  likely  to  be  virulent 
and  complicated  by  cellulitis  (phlegmonous  erysipelas). 

Treatment. — Prophylaxis,  by  careful  treatment  of  the  causes  of 
inflammation,  is  of  the  first  importance.  If  the  penis  has  already  be- 
come inflamed  it  should  be  elevated,  with  the  scrotum,  and  wet  dressings 
of  sublimate  (1:10,000)  or  aluminum  acetate  (2  per  cent)  applied 
daily.  Rest  in  bed,  free  purgation,  and  a  light  diet  are  essential  in 
the  more  severe  cases.  Tension  may  be  relieved  by  incision,  abscesses 
must  be  opened  and  drained,  and  sloughs  speedily  removed. 

Cavernitis  and  Penitis. — Inflammation  of  the  corpora  cavernosa  or 
of  all  three  erectile  bodies  arises  from  cellulitis  or  its  causes,  espe- 
cially inflammation  in  the  bulb  of  the  corpus  spongiosum. 

Course. — The  course  of  the  disease  is  that  of  an  acute  inflammation 
with  constant  priapism  and  edema  added  to  the  usual  local  symptoms. 
While  the  inflammation  may  be  walled  in  by  occlusion  of  the  vascular 
spaces,  pyemia  is  "a  terribly  frequent  complication"  (Jacobson). 

Treatment. — The  treatment  should  therefore  be  most  energetic. 
Indurations  in  the  erectile  bodies  should  be  freely  incised,  packed  to 
check  the  hemorrhage,  and  later  irrigated  frequently. 


OTHER  DISEASES  OF  THE  PENIS  AS  A  WHOLE 

Chronic  Edema. — Chronic  edema  may  be  caused  by  elephantiasis 
or  by  general  anasarca.  The  swelling  of  the  scrotum  usually  overshad- 
ows that  of  the  penis  and  may  be  so  great  as  practically  to  obliterate  that 
organ.  In  the  penis  the  edema  is  greatest  in  the  prepucb  and  especially 
about  the  frenum.  This  edema  may  offer  a  mechanical  impediment  to 
urination,  and  the  low  vitality  of  the  tissues  renders  them  especially 
liable  to  become  inflamed  by  contact  with  the  urine  that  dribbles  over 
them. 

Treatment. — The  prepuce  must  be  kept  dry  and  dusted  with  a 


648  DISEASES  OF  THE  PENIS 

soothing  powder.  Multiple  punctures  or  incisions  may  liberate  the  exu- 
date sufficiently  to  keep  the  swelling  within  bounds,  and,  these  failing, 
a  dorsal  incision  will  succeed.  Light  edema  may  be  controlled  by  band- 
aging and  elevation. 

Dilatation  of  the  Lymphatics. — This  condition  is  secondary  to 
trauma  or  ingaiinal  adenitis.  The  dilated  lymphatics  appear  as  white, 
subcutaneous  cords  encircling  the  penis  behind  the  corona  or  extending 
along  the  sides  or  dorsum.  There  are  no  subjective  symptoms  and  the 
obstruction  may  be  relieved  spontaneously.  For  esthetic  reasons  mul- 
tiple ligation  or  total  excision  may  be  resorted  to,  but  a  lymph  fistula 
may  result  from  such  treatment. 

Elephantiasis — (See  p.  553.) 

Gangrene  is  usually  the  result  of  inflammation.  It  may,  however, 
come  on  independent  of  any  local  inflammation.  Spontaneous  gangrene 
usually  occurs  in  connection  with  the  acute  exanthems.  Cases  have 
been  reported  from  typhoid,  typhus,  intermittent  fever,  and  small-pox. 
Senile  and  diabetic  gangrene  also  occur.  Cases  following  prolonged 
priapism,  iliac  thrombosis,  atheroma  of  the  dorsal  artery,  exposure  to 
cold,  and  acute  alcoholism  are  also  cited  by  Jacobson. 

Teeat:\iext. — The  prophylactic  measure — incision  of  inflammatory 
and  edematous  areas — has  already  been  noted.  AYhen  gangrene  has 
once  declared  itself,  attention  to  the  patieut's  general  condition,  the 
preservation  of  dryness,  asepsis,  and  warmth  locally,  and  the  prompt 
removal  of  all  frankly  gangTenous  tissue  are  the  therapeutic  indications. 
Later,  plastic  work  may  be  required  to  cover  areas  left  bare  of  integTi- 
ment.  Cicatricial  deformity  of  the  erectile  bodies  can  be  remedied 
only  by  time. 

Tuberculosis.- — Tuberculous  urethritis  apart,  tuberculous  ulcers 
may  appear  upon  the  glans  or  result  from  infection  during  ritual  cir- 
cumcision. The  diagnosis  depends  upon  the  pathological  examination 
of  a  snipping  from  the  ulcer. 

Treatment. — The  Finsen  light,  the  x-ray,  the  actual  cautery,  and 
simple  curettage  have  all  achieved  cures.  I  have  seen  one  case  cured 
by  the  cautery,  one  improved  by  the  x-ray. 


CHAPTER   LXVII 

PHIMOSIS— PARAPHIMOSIS— TUMORS  OF  THE  PENIS 

Preputial  Deformities.— Practically,  the  deformities  of  tlie  fore- 
skin (phimosis  and  atresia  of  the  orifice  excepted)  are  unimportant. 
The  prepuce  is  sometimes  bifid,  enlarged  into  a  pouch,  redundant,  or 
rudimentary.  When  the  prepuce  is  deficient,  the  epithelium  of  the 
uncovered  glans  penis  becomes  hard  and  tough,  mere  nearly  resembling 
ordinary  cuticle.  Under  these  circumstances  its  sensibility  is  di- 
minished, but  it  is  less  liable  to  become  excoriated  or  inflamed.  Hence, 
absence  of  the  prepuce  is  not  to  be  regretted,  and  the  operation  for  its 
restoration  (posthioplasty)  need  not  be  described. 

PHIMOSIS 

Phimosis  exists  where  the  orifice  of  the  prepuce  is  so  small  that  the 
glans  penis  cannot  be  uncovered.  The  orifice  of  the  prepuce  may  be 
congenitally  absent  (atresia  preputii).  Phimosis  is  congenital  or  ac- 
quired, simple  or  inflammatory,  or  complicated  by  other  diseases  or  by 
adhesions. 

In  young  children  preputial  redundancy  is  so  common  that  it  may 
be  considered  normal.  The  foreskin  of  an  infant  is  developed  out  of  all 
proportion  to  the  rest  of  the  penis,  taking  the  member  after  puberty  as 
a  standard  of  comparison.  Whenever  the  prepuce  can  be  fully  retracted 
there  need  be  no  anxiety  about  the  future;  the  preputial  orifice  will 
enlarge  sufficiently  before  or  at  puberty. 

Phimosis  may  be  brought  about  secondarily  through  induration  and 
inelasticity  of  the  skin  caused  by  frequent  attacks  of  preputial  inflam- 
mation. The  meshes  of  the  connective  tissue,  at  first  distended  with 
serum,  become  secondarily  thickened  and  hypertrophied,  leaving  a  thick, 
indurated,  inelastic  prepuce  that  cannot  be  retracted.  This  condition 
is  known  as  inflammatory  phimosis. 

'=-_^  Another  common  cause  of  acquired  phimosis  is  the  cicatrization  of 
multiple  chancroids  around  the  orifice  of  the  prepuce.  Infrequently, 
diabetic  eczema  produces  phimosis.  Demarquay  quotes  a  case  where  a 
passionate  and  jealous  woman  made  her  lover  wear  a  gold  padlock 
with  which  she  secured  the  preputial  orifice,  keeping  the  key  herself. 

649 


650        PHIMOSIS— PARAPHIMOSIS— TUMORS  OF  THE  PENIS 

The  victim  of  her  charms  carried  his  padlock,  which  was  replaced 
from  time  to  time  through  new  punctures,  during  four  or  five  years, 
until  such  a  degree  of  irritation  had  been  set  up  that  Petroz  and  Du- 
puytren,  when  consulted,  diagnosticated  cancer,  and  removed  the  pre- 
puce.    No  relapse  of  the  cancer  is  recorded. 

Treatment. — Circumcision  in  infancy  will  leave  the  patient  less 
subject  to  venereal  disease  and  to  sexual  irritability  in  later  years. 
For  this  reason  the  operation  has  of  late  years  attained  great  popularity. 
I  favor  it  for  all  infants  whose  foreskins  are  long  or  tight. 

A  positive  indication  for  operation  upon  a  child  does  exist,  how- 
ever, when  the  preputial  orifice  is  smaller  than  that  of  the  urethra. 
This  condition  is  evinced  by  ballooning  of  the  prepuce  during  micturi- 
tion, for  the  urine  flows  into  the  cavity  more  rapidly  than  it  can  escape 
from  the  orifice.  The  retention  of  a  drop  or  two  of  urine  in  the  cavity 
of  the  prepuce  after  each  act  of  urination  leads  to  balanitis,  suppuration, 
the  growth  of  vegetations,  formation  of  the  preputial  stone,  or  incrus- 
tation of  the  glans. 

When  the  adult  prepuce  is  tight,  an  operation  may  be  called  for, 
even  though  phimosis,  strictly  speaking,  does  not  exist.  For  example, 
the  collection  of  smegma,  or  repeated  attacks  of  herpes,  may  necessitate 
operation.  Again,  if  an  individual  with  a  tight  prepuce  gets  chancre, 
chancroid,  or  gonorrhea,  serious  inflammatory  complications  are  likely 
to  r  arise. 

PARAPHIMOSIS 

Paraphimosis  exists  when  the  prepuce  is  retracted  behind  the  corona 
glandis  and  cannot  be  replaced. 

Causes. — An  unnaturally  tight  preputial  orifice  is  a  predisposing 
cause  to  paraphimosis. 

Inflammatory  paraphimosis  may  depend  upon  balanitis,  gonorrhea, 
herpes,  chancroid,  chancre,  etc. 

Symptoms. — The  glans  penis  is  swollen  and  livid.  Behind  the 
corona,  most  marked  below,  rises  a  tense,  shining,  edematous  belt  of  the 
mucous  layer  of  the  prepuce.  Behind  this  there  is  a  deep  sulcus  or 
furrow,  most  marked  above,  often  the  seat  of  superficial  ulceration. 
Here  lies  the  stricture ;  behind  it  there  rises  another  edematous  fold, 
usually  smaller  than  the  one  in  front  (Fig.  134). 

If  the  stricture  of  the  prepuce  is  tight  enough  to  arrest  the  circula- 
tion, it  may  finally  cause  the  destruction  by  gangrene  of  all  tissues 
lying  in  front  of  it. 

Treatment. — Beduction  may  almost  invariably  be  accomplished 
without  incision,  if  the  following  details  are  observed,  viz. : 

1.  The  stricture  must  first  be  pulled  well  back.     Exceptionally  the 


Fig.  134. — Paraphimosis. 


Fig.  1.35.— Paraphimosis.     The  edema  is  squeezed  out  preparatory  to  reduction. 


651 


652        PHIMOSIS— PARAPHIMOSIS— TUMORS  OF  THE  PENIS 


mucous  membrane  is  unfolded  at  the  dorsum;  this  must  be  smoothed 
out  by  still  further  retracting  the  prepuce. 

2.  The  edema  must  be  thoroughly  squeezed  from  in  front  of  the 
stricture  to  the  shaft  of  the  penis  behind  it.     Until  one  has  patiently 

squeezed  such  a  penis  for  several  minutes,  it 
is  quite  incredible  how  fully  the  edema  may 
thus  be  reduced  and  shifted  to  the  shaft  of 
the  penis  (Fig.  135). 

3.  Keduction  is  then  accomplished  by 
forcing  the  stricture  slowly  over  the  head  of 
the  penis— so  slowly  as  to  squeeze  out  the 
remaining  edema.  It  is  futile  to  attempt  to 
pry  the  stricture  over  the  glans  until  the 
edema  has  been  reduced. 

The  following  is  the  best  method  of  re- 
duction: Seize  the  penis  behind  the  stric- 
tured  prepuce  in  the  fork  of  the  index  and 
middle  fingers  of  both  hands,  one  placed  on 
each  side.  IsTow  make  pressure  with  the  thumbs  on  both  sides,  in  such 
a  direction  as  to  compress  the  glans  laterally,  rather  than  from  before 
backward,  and  at  the  same  time  pull  the  strictured  portion  of  the  pre- 
puce forward,  the  eiTort  being  rather  to  pull  the  stricture  over  the  glans 
than  to  push  the  glans  through  the  stricture  (Fig.  136). 

If  a  prolonged,  careful  attempt  at  reduction  fails,  the  strictured 
point  must  be  divided.     This  may  be  done  under  local  anesthesia. 

After  reduction,  the  treatment  consists  in  elevation  of  the  penis 
within  a  jock  strap,  and  syringing  the  preputial  cavity  with  a  mild  anti- 
septic solution. 


Fig.  136.- 


-Reduction  of  Para- 
phimosis. 


TUMORS  OF  THE  PENIS 

Gumma — Gumma  occurs  often  in  the  glans  or  the  prepuce,  very 
rarely  in  the  urethra  and  the  corpora  cavernosa.  The  so-called  relaps- 
ing chancre  is  a  gummatous  deposit  in  the  scar  of  the  initial  lesion. 
The  history,  the  influence  of  treatment,  and,  if  necessary,  the  exam- 
ination of  a  section  of  the  growth  determine  the  diagnosis.  In  the 
corpora  cavernosa  gumma  resembles  circumscribed  fibrosis,  but  is  deeper, 
less  cartilaginous,  and  almost  always  occurs  in  the  posterior  third  of 
the  organ  (Zeissl). 

BENIGN  TUMORS  OF   THE  SKIN  AND   CONNECTIVE   TISSUE 


Cysts — Implantation,  and  sebaceous  cysts  occur 
in  the  sebaceous  glands  of  the  skin  or  in  Tyson's  glands. 


The  last  originate 


Cysts  occur 


TUMORS  OF  THE  PENIS  653 

almost  always  in  the  prepuce  and  are  readily  enucleated.     (Cf.  Geru- 
lanos/) 

Benign  Neoplasms. — Lipoma,  adenoma,"  and  angioma  liave  been 
described.  Tbey  are  rare,  and  their  removal  is  a  question  of  judg- 
ment involving  a  recognition  of  the  function  of  the  penis  as  an  intro- 
mittent  organ,  and  the  possible  loss  of  this  function  from  the  fonnation 
of  a  cicatrix. 

Papilloma — More  important  because  of  their  frequency  are  the 
papillomata  (condylomata  acuminata)  of  the  penis.  They  are 
commonly  denominated  venereal  warts.  This  title,  however,  is  not 
exact,  since  there  is  no  necessary  connection  between  them  and  any 
venereal  disease.  They  are  papillary  overgrowths,  often  highly  vascular, 
and  composed  of  epithelium.  They  may  be  prominent  and  peduncu- 
lated, or  flat,  and  growing  from  a  considerable  surface.  They  are 
nearly  always  multiple.  They  are  caused  by  inflammation,  or  simply 
by  lack  of  cleanliness.  Consequently  the  most  favorable  condition  for 
their  production  exists  in  gonorrhea,  in  balanitis,  or  when  mucous 
patches  occupy  the  cavity  of  the  prepuce.  Their  favorite  seat  is  just 
behind  the  corona  glandis,  but  they  are  also  encountered  anywhere 
within  the  cavity  of  the  prepuce,  at  its  orifice,  upon  its  cutaneous  sur- 
face, or  even  within  the  urethra.  They  are  found  also  upon  the  scro- 
tum, and  frequently  around  the  anus.  They  are,  when  numerous, 
bathed  in  a  fetid,  puriform  secretion,  and  may  grow  large  enough 
within  the  prepuce  to  cause  phimosis.  They  occur  upon  young  chil- 
dren, and  are  found  in  their  greatest  luxuriance  within  and  around 
the  vulvae  of  women  affected  with  irritating  discharges — discharges  not 
necessarily  venereal  in  any  sense. 

Implantation  warts  also  occur  after  circumcision. 

Diagnosis. — ^Warts  should  be  differentiated  from  mucous  patches 
and  condylomata  lata  by  the  typical  flat  appearance  of  the  syphilitic 
lesions  and  the  accompanying  symptoms  of  the  disease. 

From  commencing  epithelioma  the  diagnosis  may  be  extremely  dif- 
ficult. When  in  doubt  examine  a  snipping  under  the  microscope,  and 
if  it  appears  benign,  treat  it  as  such,  but  remove  it  in  any  case.  If  it 
recur,  and  the  patient  is  over  fifty,  it  is  safest  to  exsect  it  as  though  it 
were  epitheliomatous,  whatever  the  findings  of  the  pathologist.  Radium 
is  very  efficient  for  this  class  of  cases. 

Peognosis. — Unless  kept  scrupulously  clean,  warts  sometimes  ulce" 
ate,  and  they  may  even  suppurate,  light  up  suppurating  buboes,  and 
even  cause  gangrene  of  the  penis.  Simple  cleanliness,  on  the  other  hand, 
often  causes  them  to  atrophy. 

Epitheliomatous  degeneration  may  take  place,  and  is  always  to  be 

^Deutsche  Zeitschr.  f.  Chir.,   1900,  Iv,  326. 
*" Morrow '3  System,"  1893,  i,  58. 


654        PHIMOSIS— PARAPHIMOSIS— TUMORS  OF  THE  PENIS 

feared.  Implantation  warts  are  especially  liable  to  hypertrophy  and 
become  horns. 

Teeatmext. — Eepeated  washing  with  soap  and  water  followed  by 
the  application  of  calomel  often  causes  vegetations  to  shrink  up  and 
disappear.  In  any  case  this  is  essential.  In  case  vegetations  are  com- 
plicated by  balanitis,  treatment  of  the  latter  will  often  at  the  same  time 
triumph  over  the  warts.     But  circumcision  is  usually  required. 

The  most  valuable  local  application  is  a  10  per  cent  mixture  of  sali- 
cylic acid  in  acetic  acid.^  This  forms  a  chalk  and  water  mixture  of 
which  the  moist  chalk  is  smeared  over  the  warts.  One  or  two  applica- 
tions cause  the  gTOwths  to  wither  away  and  drop  off.  If  they  persist, 
however,  all  the  pedunculated  growths  may  be  removed  with  curved 
scissors,  and  the  surface  from  which  they  grow  cauterized  with  nitric 
acid  or  any  other  escharotic.  The  x-ray,  the  high  frequency  current, 
and  radium  are  efficacious  for  obstinate  cases.  Lactic  acid — pure  for 
small  lesions,  in  one  per  cent  solution  for  extensive  ones — is  highly 
spoken  of  by  Watson.^ 

Horns. — Horny  growths  may  spring  from  the  glans  or  the  in- 
tegument. They  begin  as  warts  and  are  very  prone  to  epitheliomatous 
change.  Brinton  ^  has  described  a  curious  case  and  collected  others 
from  the  literature.     Baldwin  ^  and  Bruce  Clark  ^  mention  others. 

BENIGN  TUMORS  OF  THE  ERECTILE  BODIES 

The  benign  tumors  of  the  erectile  bodies  of  the  penis  are  four:  cir- 
cumscribed fibrosis^  encliondroma,  osteoma,  and  calcification.  The  first 
is  comparatively  rare,  the  others  extremely  so. 

Circumscribed  Fibrosis — I  have  come  to  prefer  this  name  for 
the  malady  heretofore  usually  known  as  chronic  circumscribed  inflam- 
mation of  the  corpora  cavernosa,  for  the  condition  is  a  fibrosis,  not  an 
inflammation. 

The  malady  is  gouty  in  origin,  comparable  to  Dupuytren's  contrac- 
tion of  the  palmar  fascia.  It  usually  appears  between  the  ages  of  thirty- 
five  and  fifty. 

Pathology. — The  growth  occurs  in  the  sheath  of  the  erectile  body. 
It  is  a  fibrosis  which  may  show  patches  of  enchondroma  (Stopczanski  ^). 

Symptoms. — The  affection  comes  on  insidiously,  without  apparent 
cause,  although  the  patient  sometimes  ascribes  it  to  injury.  The  first 
symptom  is  a  bending  or  a  slight  pain  at  a  certain  point  in  the  penis 

^  Not  glacial. 

""  Lancet,  Apr.,  13,  1913,  No.  4624. 

""Med.  News,  1887,  li,  141. 

♦  Ibid.,  449. 
'•Lancet,  1894,  i,  219. 

*  Wien.  klin.  Wochenschr.,  1908,  xxi,  318. 


TUMORS  OF  THE  PENIS  655 

when  the  organ  is  erect.  Examination  detects  a  hard,  flattened  mass 
with  sharply  defined  margins,  occupying  one  or  both  corpora  cavernosa 
near  the  surface,  and  feeling  like  cartilage — elastic,  springy,  not  as 
bony  as  a  calcareous  plate.  The  corpus  spongiosum  does  not  participate 
in  the  disease.  The  penis  bends  during  erection  at  the  affected  point, 
and  along  the  edge  of  the  hardness  a  little  pain  is  experienced.  This 
indurated  mass,  which  is  usually  irregularly  oval  in  shape,  may  remain 
stationary  for  an  indefinite  period ;  or  it  may  progress  slowly  backward 
or  forward,  sometimes  retaining  its  size  and  shape,  sometimes  growing 
larger,  sometimes  smaller. 

A  slight  tenderness  is  perhaps  felt  along  the  line  of  advancing  in- 
duration, and  moderate  uneasiness  is  usually  produced  by  pressing  the 
induration  between  the  fingers  or  by  erection.  The  seat  of  election  is 
the  septum  and  adjacent  portions  of  the  sheath  on  the  dorsum  of  the 
penis,  not  far  from  the  glans. 

Prognosis. — The  prognosis  is  negatively  good  in  that  the  fibrous 
mass  never  ulcerates  or  becomes  cancerous,  may  get  spontaneously 
better,  even  possibly  well,  or  may,  and  sometimes  does,  develop  back- 
ward until  it  gets  so  low  down  toward  the  root  of  the  penis  that  it  no 
longer  seriously  interferes  with  upright  erection.  I  have  seen  more  than 
one  patient  who,  at  one  time  being  debarred  from  sexual  intercourse, 
has  by  a  shifting  of  the  position  of  the  induration  again  become  potent. 
I  have  met  one  person  with  a  distinct  plaque  of  some  size,  of  which  he 
had  no  knowledge  whatever.  The  distinction  between  fibroma  and  en- 
chondroma  can  only  be  made  pathologically ;  clinically  it  is  unim- 
portant. The  tendency  to  ossification  manifests  itself  so  rarely  that 
it  is  a  negligible  quantity. 

Treatment. — An  effective  treatment  of  this  singular  malady  is 
yet  to  be  discovered.    Thus  far  time  only  has  seemed  to  help  it. 

Thiosinamin,  antisclerosin  injections,  blisters,  oleate  of  mercury, 
tincture  of  iodin,  the  iodids,  and  electrolysis,  have  uniformly  failed. 
Excision  only  replaces  the  fibrosis  by  scar  tissue.  Piperazin  is  well 
spoken  of. 

Calcification  and  Ossification. — Both  of  these  conditions  are  usually, 
probably  always,  secondary  to  fibrosis,  or  enchondrosis  of  the  erectile 
bodies.  Calcification  of  small  patches  is  quite  rare,  ossification  is  even 
more  unusual.  Cases  of  this  latter  condition  have  been  reported  by  von 
Lenhossek,^  Demarquay,^  Porter,^  Jacobson,^  and  Chetwood.^  In  Chet- 
wood's  specimen  certain  spots  were  simply  fibrous,  others  were  cartilagi- 

^  Virchow's  Archiv,  1874,  Ix,  i. 

^Op.  cit.,  p.  354. 

""N.Y.  Med.  Record,  1882,  270. 

*0p.  cit.,  p.   683. 

''Jour,  of  Cut.   and    Gen.-Vrin.   Bis.,   1899,   xvii,   231. 


656        PHIMOSIS— PARAPHIMOSIS— TUIVIORS  OF  THE  PENIS 

nous,  while  the  bulk  of  the  growth  was  true  bone.  To  compare  penile 
osteoma  with  the  bony  development  normal  in  the  penes  of  certain 
monkeys  is  scarcely  logical. 

Pkognosis. — Calcification  or  ossification  may  cease  after  more  or 
less  of  each  corpus  cavernosum  has  suffered,  or  it  may  involve  the  whole 
organ  pretty  generally.  Sexual  intercourse  may  be  seriously  interfered 
with,  if  not  prevented  altogether. 

Teeatmext. — Medicine  holds  out  no  hope  to  the  sufferer.  If  the 
disease  has  come  to  a  standstill  and  the  deposit  is  superficial  and  small, 
it  may  be  removed  with  the  knife — an  operation  which  has  been  per- 
formed with  success  by  Eegnoli,  MacClellan,  and  Huitfeldt.-^ 


MALIGNANT  NEOPLASMS  OF  THE  PENIS 

The  primary  malignant  new  growths  of  the  penis  are  sarcoma  and 
epithelioma.  The  former  is  very  rare.  It  arises  from  the  erectile 
bodies,  usually  the  corpora  cavernosa.  The  latter,  much  more  common, 
begins  on  the  glans  or  on  the  prepuce.  (Epithelioma  of  the  urethra  is 
considered  with  the  other  diseases  of  that  canal.") 

Secondary  new  growths  present  no  peculiar  features.  They  either 
form  part  of  a  disseminated  carcinosis  or  are  mere  extensions  of  the 
tumor  from  an  adjoining  region,  usually  the  scrotum. 

Sarcoma. — With  or  without  previous  trauma  a  tumor  appears  in 
one  of  the  erectile  bodies.  The  fact  that  it  is  a  distinct  lump  and  not 
a  flat  indurated  patch' readily  distinguishes  it  from  the  benign  tumors 
of  these  structures.  Moreover,  sarcoma  usually  appears  in  early  man- 
hood and  develops  with  characteristic  rapidity  and  early  involvement  of 
the  inguinal  glands.  Exceptionally,  however,  it  grows  slowly  and  the 
glandular  involvement  occurs  late.  Of  the  13  cases  recorded  by  Jacob- 
son  -  some  arose  from  the  erectile  tissue,  some  from  the  fibrous  sheath, 
and  one — a  melanotic  sarcoma — apparently  originated  in  the  urethral 
mucous  membrane.  The  earlier  cases  were  reported  as  fibroma  or 
carcinoma.  As  the  tumor  grows  it  causes  priapism  by  occluding  the 
cavernous  spaces,  and  may  also  occlude  the  urethra  and  so  cause 
retention  of  urine.  Early  amputation  of  the  penis  is  the  only  treatment. 
The  pror/nosis  is  absolutely  bad. 

Epithelioma.- — Epithelioma  of  the  penis  (Fig.  135)  begins  on  the 
prepuce  or  glans,  both  of  which  are  usually  involved  when  the  patient 
presents  himself  for  examination. 

Though  Freyer  ^  has  reported  a  case  in  a  youth  of  seventeen,  and 
Kaufmann  places  6  per  cent  of  the  cases  in  the  third  decade,  here,  as 

'  Norsk  Mag.  f.  Laegevid.,  1910,  Ixxi,  No.  1. 

'  Op.  cit.,  p.  738. 

'Brit.  Med.  Jour.,  1891,  i,  1173. 


TUMORS  OF  THE  PENIS 


657 


elsewhere,  epithelioma  is  usually  a  disease  of  later  life.  One  case  de- 
veloped in  the  scar  of  a  horse-bite,  others  have  arisen  from  the  scars  left 
by  venereal  sores,  a  few  from  urethral  fistula ;  but  warts  and  chronic 
balanitis  are  the  most  fruitful  sources  of  epithelioma,  the  former  espe- 
cially if  neglected  and  allowed  to  remain  foul  and  moist.  Indeed,  29 
out  of  33  cases  collected  by  Kaufmann  began  as  apparently  benign 
warts.  Finally,  phimosis  is  a  marked  predisposing  cause  of  epithelioma. 
By  retention  of  the  smegma  and  urine  it  predisposes  the  patient  to 


Fig.  137. — Epithelioma  of  the  Penis  (Wyeth). 


balanitis,  vegetations,  and  fissures  of  the  foreskin,  and  these  processes 
once  set  up  are  kept  concealed  and  constantly  bathed  in  an  acrid  and 
irritating  fluid.  Demarquay  noted  phimosis  in  42  out  of  59  cases,  and 
it  is  claimed  that  the  circumcised  Jew  is  exempt  from  penile  epitheli- 
oma. The  question  of  inoculation  from  cervix  uteri  is  agitated  from 
time  to  time,  but  the  extreme  rarity  of  the  cases  adduced  indicates 
that  they  represent  nothing  more  than  a  curious  coincidence. 

Symptoms  and  Course. — Although  epithelioma  of  the  penis  is  not 
often  seen  until  well  under  way  and  absolutely  characteristic,  the  vari- 
ous aspects  under  which  it  first  presents  itself  must  be  appreciated  in 
order  that  intelligent  radical  treatment  may  be  resorted  to  early. 

In  about  5  out  of  6  cases  the  disease  begins  as  a  wart  situated  on  the 


658        PHIMOSIS— PARAPHIMOSIS— TUMORS  OF  THE  PENIS 

glans  or  on  the  inner  surface  of  the  prepuce.  This  wart  is  intractable 
to  ordinary  methods  of  treatment,  and  recurs  if  cut  or  burned  away. 
As  it  grows  it  assumes  a  lobulated,  cauliflower  appearance,  and  soon 
begins  to  ulcerate  in  places,  and  to  exude  the  characteristic  foul  ichorous 
discharge.  Then  the  base  gradually  takes  on  the  hard  induration  of  the 
epitheliomatous  ulcer  with  everted  edges.  By  this  time  the  inguinal 
glands  are  probably  involved  and  may  be  felt  as  shotty  subcutaneous 
nodules  in  either  groin.  (For  the  lymphatics  of  the  penis  so  anastomose 
that  a  so-called  crossed  bubo — the  sore  on  the  one  side  of  the  penis  and 
the  bubo  in  the  opposite  groin — occurs  not  infrequently. ) 

More  rarely  epithelioma  begins  as  a  raw  spot  or  an  indolent  ulcer, 
and  still  more  rarely  it  appears  first  as  a  subcutaneous  nodule  or  as 
a  patch  of  leukoplakia. 

In  whatever  way  the  disease  begins,  it  comes  after  a  time  to  the 
frankly  cancerous  stage.  The  ulcer  advances,  involving  all  the  tissues 
in  its  path ;  the  discharge  is  thin,  sanious,  fetid ;  the  ulcer  deep,  irregu- 
lar, unhealthy,  its  edges  hard,  livid,  and  everted.  At  the  same  time 
the  exuberant  warty  growth  progTesses,  either  of  these  conditions 
predominating  to  make  the  case  clinically  a  warty  or  an  ulcerative 
lesion. 

The  inguinal  glands  now  become  prominent  and  partake  of  the  py- 
ogenic as  well  as  of  the  cancerous  infection,  so  that  they  become  matted 
together,  and  may  even  suppurate  or  produce  an  epitheliomatous  ulcer 
in  the  groin. 

Locally,  the  growth  may  spread  over  quite  a  large  superficial  area 
without  involving  the  corpora  cavernosa,  but  when  these  become  in- 
vaded secondary  growths  develop  to  their  very  depths.  Involvement 
of  the  corpus  spongiosum  results  in  stricture. 

Lancinating  pain  is  a  prominent  symptom  only  late  in  the  disease. 
The  chief  inconveniences  to  the  patient  in  the  earlier  stages  are  the 
presence  of  the  growth,  the  foul  discharge,  the  tendency  to  annoying 
hemorrhage  after  the  slightest  abrasion,  and  urethral  stricture.  As  the 
disease  advances  the  strength  of  the  patient  fails.  The  tumor  spreads 
up  over  the  penis  to  the  pubes,  abdomen,  and  thighs,  joining  the  ulcer- 
ated inguinal  glands  and  extending  down  over  the  scrotum  to  the  peri- 
neum, anus,  and  buttocks,  until,  finally,  the  patient  dies  of  sepsis, 
cachexia,  or  hemorrhage. 

Diagnosis. — The  diseases  which  may  be  confused  with  epithelioma 
of  the  penis  are  warts,  chancre,  chancroid,  tuberculous  ulcers,  and  ulcers 
from  chronic  balanopostliitls. 

As  we  have  seen,  the  appearance  of  epithelioma  is  characteristic 
enough  after  its  base  has  become  indurated  and  the  infection  has  begim 
to  spread  to  the  inguinal  glands ;  but  it  is  of  the  greatest  importance  that 
the  diagnosis  be  made  before  that  time,  while  the  disease  is  yet  emi- 


TUMORS  OF  THE  PENIS  G59 

nently  curable.  To  this  end  all  growths  or  ulcers  that  prove  intractable 
should  be  regarded  with  suspicion,  and  if  that  suspicion  is  confirmed  by 
microscopical  examination  of  a  snipping  from  the  diseased  tissue,  im- 
mediate operation  should  be  insisted  upon. 

Prognosis. — Before  the  inguinal  glands  become  involved  the  oper- 
ative prognosis  is  good.  Afterwards  it  is  bad,  yet  not  absolutely  so,  for 
cures  are  reported  in  cases  where  unmistakable  gland  involvement  had 
occurred. 

Tkeatmext. — If  the  growth  be  seen  before  induration  has  occurred 
it  may  usually  be  removed  by  circumcision  if  on  the  prepuce,  or  by 
thorough  cauterization  if  upon  the  glans.  Patches  of  leukoplakia  upon 
the  glans  penis  or  the  foreskin  should  be  promptly  destroyed  by  knife 
or  cautery.  The  patient  should,  however,  be  warned  of  the  danger  of 
recurrence,  and  should  this  appear,  or  should  there  be  some  induration 
about  the  base  of  the  tumor,  the  penis  must  be  amputated  behind  the 
corona,  and  the  inguinal  glands  of  both  sides  extirpated,  whether  they 
are  palpably  enlarged  or  not,  for  the  microscope  has  repeatedly  shown 
these  glands  to  be  the  seat  of  malignant  deposits  though  their  gross 
appearance  was  quite  normal. 

If  the  glans  is  extensively  involved,  the  penis  must  be  amputated 
close  up  to  the  pubes,  or  else  extirpated  entirely.  Jacobson  claims  that 
simultaneous  castration  adds  to  the  comfort  of  these  patients,  though 
most  men  refuse  to  part  with  their  testicles  even  when  their  function 
has  thus  ceased. 

Barney  reported  100  cases.^  Though  80  recurred  within  five  years 
(and  12  thereafter),  11  out  of  26  cases  operated  upon  for  recurrence  re- 
mained well  five  years  thereafter.  Though  excision  of  the  inguinal 
glands  is  imperatively  required  for  all  but  the  earliest  cases,  it  is  note- 
worthy that  -20  were  cured  by  primary,  and  8  by  secondary,  amputation 
without  adenectomy,  while  only  six  were  cured  after  the  combined  op- 
eration: in  other  words,  almost  all  the  advanced  cases  die  in  spite  of 
operation. 

^Ann.  Surg.,  Dec,  1907,  p.  890. 


CHAPTER  LX\n:ii 


CHANCROID 


Chan"ceoid  (or  soft  chancre)  and  hard  chancre  are  no  more  akin 
than  measles  and  leprosy;  and  it  is  unfortunate  that  the  ancient  con- 
fusion of  the  local  and  the  general  infection  has  left  us  this  legacy  of 
misleading  terms ;  but  it  is  now  too  late  to  change  them. 

Chancroid  is  a  specific^  local,  contagious,  auto-infectious  venereal 
ulcer. 

It  is  specific  in  that  it  is  caused  by  a  specific  microorganism,  the 
streptobacillus  of  Ducreyi 

This  bacillus  is  dumb-bell  shaped,  thick  and  rounded  or  square  at 

the  ends,  constricted  in  the  middle. 
It  varies  in  length  from  1.5  to  2  t^- 
It  groups  in  parallel  chains,  and  oc- 
curs both  inside  and  outside  the  cells 
(Fig.  138).  It  stains  readily  with 
U  \tf^^ffil    %.    '"^W     A    ^^^   ordinary    dyes    (methylene-blue, 

MP         iSR^V  S    ^""^  "^^0^6^?  ^^  fuchsin),  and  is  decol- 

\^~  •«.»,,  ,^..,  ^^'  ^    orized  by  the  Gram  stain. 

For  many  years  after  its  discov- 
ery in  1889,  in  spite  of  the  confirma- 
tory observations  of  Fnna,  Kretling, 
Dubreuilh,  and  Lasnet,  etc.,  and  in 
face  of  the  manifestly  specific  char- 
acter of  chancroid,  the  pathogenic 
action  of  the  streptobacillus  was 
doubted  until  proven  by  the  culture  and  inoculation  experiments  of 
Istamanoff  and  Askpianz,-  Lincoln  Davis,^  Lancret,^  and  Tomasczew- 
ski.'^  But  chancroid  is  peculiarly  liable  to  mixed  infection,  A  smear 
taken  from  the  surface  of  the  ulcer  usually  shows  numerous  pyogenic 
and  other  bacteria,  and  few  if  any  of  the  pathogenic  bacilli.  Hence 
such  a  smear  cannot  be  dej)ended  upon  for  diagnosis. 


^-..*"^->^ 


Fig 


138. STREPTOHAriLLT'S  OF  DUCREY. 

(Lincoln  Davis.) 


^Biforma  medica,  1889,  vol.  v,  p.  98. 

"  Jahresbericht  d.  Path. — Microorg.,  1898,  vol.  xiv. 

'Jour,  of  Med.  Research,  1904,  vol.  ix,  p.  401. 

*Bull.  mid.,  1898,  vol.  xii,  p.  1051. 

^Zeitschr.  f.  llygiene  u.  Infect.,  1903,  vol.  xiii,  p.  327. 

660 


FREQUENCY  661 

Chancroid  is  a  local  lesion,  causing  no  systemic  infection  or  reaction. 
It  is,  therefore,  indefinitely  auto-inoculable.  Indeed,  the  marked  tend- 
ency to  auto-inocnlation  is  one  of  the  most  striking  clinical  character- 
istics of  the  ulcer.  That  it  confers  no  imniunity  whatever  was  amply 
proven  by  the  disciples  of  syphilization.  Lindemann,  for  example,  in- 
oculated himself  2,700  times  with  chancroidal  pus  in  the  vain  hope  of 
immunizing  himself  against  syphilis.  But  a  local  and  temporary  im- 
munity does  exist ;  for  after  many  inoculations  a  given  region  becomes 
temporarily  immune,  though  the  virus  will  still  take  on  other  parts  of 
the  body. 

Clinically,  however,  such  immunity  has  no  sig-nificance. 

Finally,  chancroid  is  a  contagious  venereal  ulcer.  ISTot  once  in  a 
hundred  cases  does  one  see  a  chancroid  except  about  the  genitals. 
This  is  as  much  as  to  say  that  it  is  practically  always  acquired  by 
sexual  contact.  Although  many  cases  of  mediate  contagion  have  been 
reported  (the  virus  being  usually  conveyed  by  the  hand),  such  cases 
are  proportionately  extremely  rare.  Indeed,  chancroid  will  not  "take" 
upon  the  integTiment  unless  it  is  abraded.  Cullerier's  experiments  show 
that  this  must  oftentimes  be  true  of  the  vagina  as  well.  In  two  cases  he 
deposited  pus  from  a  chancroidal  bubo  in  a  clean  vagina,  and  let  it  re- 
main there  between  half  an  hour  and  an  hour.  Then  some  of  the 
vaginal  secretion  was  collected  and  inoculated  upon  the  thigh,  after 
which  the  vagina  was  thoroughly  cleansed.  In  both  instances  typical 
chancroids  developed  on  the  thigh  while  the  vagina  remained  clean. 

Hence,  be  it  noted,  a  woman  may  convey  chancroid  from  one  man 
to   another  without  herself  becoming  infected. 

Yet  auto-inoculation  of  chancroid  upon  the  healthy  skin  or  mucous 
membrane  lying  in  contact  with  it  is  extremely  common.  But  it  takes 
many  hours  of  intimate  contact  to  effect  the  inoculation. 


FREQUENCY 

In  the  clinic,  chancroids  outnumber  true  chancres  two  to  one.  In 
private  practice  the  preponderance  is  reversed,  and  we  see  five,  or  even 
ten,  chancres  to  one  chancroid.  The  reason  for  this  is  twofold.  In 
the  first  place,  chancroid  can  never  make  headway  among  cleanly  per- 
sons, for  it  is  so  foul  and  disgusting  that  no  decent  citizen  infected  with 
it  would  attempt  sexual  intercourse  until  it  is  cured,  and  half  a  cure — 
such  as  so  commonly  conceals  the  infectiousness  of  syphilis  and  gonor- 
rhea— is  here  impossible.  In  the  second  place,  in  most  instances,  a 
little  soap  and  water  at  the  time  of  exposure  is  an  absolute  safeguard 
against  it. 

Chancroid  flourishes  only  where  soap  and  water  are  not  esteemed. 


662 


CHANCROID 


SITUATION  AND  NUMBER 

Chancroids  upon  the  male  genitals  are  most  common  in  the  coronary 
sulcus,  especially  in  the  little  pocket  on  each  side  of  the  frenum.  Ure- 
thral chancroid  is  extremely  rare. 

In  women  the  sores  usually  occur  about  the  introitus,  rarely  higher 
up. 

From  these  regions  the  ulcers  may  spread  by  contact  or  by  direct 
extension  over  external  genitals,  anus,  thighs,  abdomen,  and  even  far- 
ther afield. 

Chancroid  commonly  begins  as  a  single  ulcer ;  but  no  sooner  has  this 
appeared  than  secondary  ulcerations  begin,  so  that  by  the  time  the 
physician  is  consulted  several  sores  are  usually  present. 

SYMPTOMS  AND  COURSE 


Incubation. — The  disease  has  an  incubation  period  varying  from 
one  to  ten  days,  usually  three  to  five.  A  protracted  incubation  is  proba- 
bly due  to  the  fact  that  the  virus  is  retained  some  days  within  the 

prepuce  (or  vagina)  before 
inoculation  occurs. 

Onset — The  symptoms 
of  chancroid  are  best  ob- 
served by  studying  the 
course  of  the  artificial  ulcer 
produced  by  inoculation. 
Within  twenty-four  hours 
after  such  an  inoculation  a 
reddish  blush  surrounds 
the  puncture.  This  soon 
changes  to  an  inflamed 
areola  which,  in  the  third 
day  (rarely  sooner  or 
later),  becomes  a  pustule. 
This  extends  quite  rapidly, 
and  within  a  few  days 
breaks  and  becomes  a  char- 
acteristic chancroidal  ulcer 
(Fi.o-.  139). 

The  Ulcer. — The  typ- 
ical chancroid  is  a  round 
ulcer  with  undermined  or 
perpendicular    edge.       The 


Fig.  139. — Chancroids  of  Prepuce,  PREPUTivL 
Frenum,  and  Glans  Penis,  in  Various  Stages 
OF  Development.     (Kaposi.) 


COMPLICATIONS  663 

ulcer  is  usually  rather  deep.  Its  base  is  irregular,  grayish  yellow,  and 
covered  by  a  pultaceous  false  membrane.  It  is  surrounded  by  a  non- 
indurated,  inflammatory  areola.  The  secretion  is  abundant  and  puru- 
lent.    It  bleeds  readily.     It  may  be  intensely  painful. 

CouKSE. — If  untreated  and  uncomplicated  the  ulcer  increases  in 
size  for  a  week  or  two.  Then,  having  attained  a  diameter  of  about  1 
cm.,  it  remains  stationary  for  about  two  weeks,  and  then  gTadually 
heals  by  cicatrization  from  the  edges  toward  the  center.  So  rarely, 
however,  is  the  ulcer  both  uncomplicated  and  untreated  that  the  stage 
of  spontaneous  healing  is  not  seen  in  the  clinic. 


COMPLICATIONS 

The  common  complications  of  chancroid  are  mixed  infection  with 
syphilis  (mixed  sore),  mixed  infection  with  pyogenic  microbes  (in- 
flamed chancroid),  destruction  of  the  frenum,  phimosis,  gangrene  and 
phagedena,  balanoposthitis  and  venereal  warts,  lymphangitis,  adenitis 
(bubo). 

The  Mixed  Sore. — So  long  as  your  patient  has  chancroid  you  may 
never  he  sure  that  he  has  not  chancre.  This  rule  is  without  exception. 
A  chancroid  may  readily  conceal  a  chancre  from  the  most  experienced 
eye.     A  chancroid  may  refuse  to  heal  because  of  complicating  gumma. 

A  very  large  proportion  of  sores  treated  in  the  clinic  as  chancroids 
are  actually  chancres,  for  many  cases  of  unsuspected  syphilis  date  back 
to  a  "chancroid." 

The  Inflamed  Chancroid. — While  every  chancroid  is  more  or  less 
irritated  by  its  own  secretions  and  contaminated  by  ordinary  pyogenic 
microbes,  the  resulting  inflammation  is  often  insignificant  unless  ac- 
centuated by  friction. 

The  chancroid  at  the  preputial  orifice  is  usually  an  interminal)le 
while  getting  well.  The  friction  of  shirt  and  drawers,  or  even  the  rub- 
bing of  the  softest  dressing,  so  irritates  the  sore  that,  though  it  may 
lose  all  its  chancroidal  characteristics  and  become  a  simple,  sluggish 
abrasion,  it  lingers  on  week  after  week,  taxing  to  the  utmost  the  victim's 
patience  and  the  physician's  skill. 

Chancroid  underneath  a  long  prepuce,  however  loose,  usually  ex- 
cites so  acute  a  cellulitis  in  the  connective  tissue  of  the  foreskin  as  to 
cause  inflammatory  phimosis.  This  retains  the  secretions  of  the  chan- 
croid, which,  bathed  in  this  irritating  pus  and  protected  from  effective 
treatment,  promptly  invades  both  glans  and  prepuce,  and  instead  of 
healing  tends  rather  to  eat  its  way  through  the  glans  penis  into  the 
urethra  or  through  the  foreskin,  at  the  same  time  setting  up  an  intense 
inflammation,  which  may  terminate  in  abscess,  erysipelas,  or  gangrene. 


664  CHANCROID 

If  the  prepuce  is  retracted  in  a  desperate  effort  to  get  at  the  suppurating 
cavity,  paraphimosis  complicates  matters. 

Destruction  of  the  Frenum. — One  of  the  commonest  complications 
of  chancroid  is  destruction  of  the  preputial  frenum. 

The  frenum  is  destroyed  in  the  following  manner :  a  chancroid  ap- 
pears in  the  sulcus  at  one  or  both  sides  of  the  frenum ;  as  it  enlarges  it 
eats  a  hole  in  the  frenum,  leaving  a  narrow  string,  which  soon  gives  way 

as  well. 

Gangrene  and  Phagedena. — The  terrible  phagedena  which,  until 
the  era  of  antisepsis,  was  an  imminent  possibility  for  every  case  of 
chancroids,  has  almost  passed  into  oblivion  with  hospital  gangrene  and 
such  ancient  horrors.  One  can  no  longer  imagine  such  a  case  as  Eicord 
treated  for  several  years^,  and  which,  commencing  as  a  chancroidal 
bubo  fourteen  years  before,  was  still  an  open  ulcer  at  the  knee — indeed, 
this  may  well  have  been  a  gumma. 

On  the  other  hand,  gangrene  foudroyante  is  still  occasionally  en- 
countered as  the  complication  of  stricture,  or  of  chancroid.  Thus  Mar- 
tin ^  relates  and  depicts  the  case  of  a  man  who  lost  two-thirds  of  his 
penis  by  gangrene  in  thirty-six  hours.  Happily,  such  cases  are  ex- 
tremely rare. 

Most  "phagedenic  chancroids"  are  gummata  with  a  negative  Wasser- 
mann  reaction. 

Lymphangitis — Acute  inflammation  of  the  lymphatics  running 
along  the  dorsum  and  sides  of  the  penis  toward  the  inguinal  glands  is  a 
rare  complication.     Suppuration  therein  is  much  rarer. 

Inguinal  Adenitis — Chancroid  of  the  genitals  causes  inguinal  ade- 
nitis or  bubo.  This  complication  occurs  about  once  in  every  three  cases. 
The  bubo  when  bilateral  is  usually  moi  e  severe  on  the  side  upon  which 
the  sore  lies;  but,  on  account  of  an  abnormal  lymphatic  supply,  the 
glands  in  the  opposite  gToin  may  be  the  more  inflamed.  This  is  the 
so-called  "crossed  bubo." 

The  chancroidal  bubo  may  be  a  simple  inflammatory  adenitis,  the 
glands  becoming  large  and  quite  tender,  so  remaining  for  a  week  or 
more,  and  then  slowly  resolving. 

It  may  go  on  to  peri-adenitis.  The  glands  become  matted  together 
in  irregular,  tender  masses  adherent  to  the  skin  and  to  the  subjacent 
tissues.  When  the  inflammation  reaches  this  stage  it  terminates  bj 
suppuration.  When  the  abscess  is  incised  or  breaks,  it  usually  forms  a 
chancroidal  ulcer.     This  is  the  so-called  virulent  bubo. 

It  has  long  been  known  that  chancroidal  pus,  although  it  would 
remain  virulent  for  many  weeks  if  kept  in  a  sealed  tube,  promptly  lost 
its  virulence  when  heated  to  a  temperature  of  105°  F.  It  is,  therefore, 
to  be  inferred  that  both  "simple"  and  "virvilent"  buboes  are  due  to 

^JVIorrow's  "System,"  p.   875, 


DIAGNOSIS  665 

infection  by  tlie  streptobacillus,  but  that  the  heat  engendered  in  the  in- 
flamed gland  is  sufficient  to  reduce  its  virulence  sometimes  to  the  point 
of  rendering  it  temporarily  innocuous ;  so  that  it  only  requires  a  few 
days  of  cooling  off,  as  it  were,  in  the  open  ulceration  to  regain  its  prim- 
itive vigor.  ^ 

DIAGNOSIS 

The  diagTiosis  of  chancroid  may  be  made  by  the  microscope  (which 
gives  no  negative  assurance),  by  culture  on  blood  agar,  by  the  ancient 
and  very  trustworthy  method  of  auto-inoculation,^  or  by  confrontation 
(examination  of  the  person  from  whom  the  sore  was  contracted). 

Generally  speaking,  however^  no  test  is  required  to  establish  the 
diagnosis  of  chancroid.  The  multiple,  virulent  sloughing  ulcers,  spread- 
ing by  contact  inoculation,  the  characteristic  bubo,  and  the  history  of 
very  recent  exposure  form  a  typical  clinical  picture.  Inflamed  herpes  or 
simple  ulcer  may,  however,  very  closely  simulate  beginning  chancroid. 
Moreover,  the  chancroid  may  originate  in  the  orifice  of  a  sebaceous 
gland  of  the  scrotum  or  penis  (follicular  chancroid),  and  so  be  mis- 
taken at  first  for  a  small  boil  or  an  acne  pustule.  Bullous  and  ecthyma- 
tous  forms  of  chancroid  are  extremely  rare. 

But  the  really  important  point  in  the  diagnosis  of  chancroid  is  its 
differentiation  from  true  syphilitic  chancre.  The  details  of  this  differ- 
entiation are  considered  elsewhere  (p.  821)  ;  but  it  is  not  amiss  to  re- 
peat once  again  that  no  matter  how  sure  you  may  he  that  a  given  sore  is 
a  chancroid^  you  cannot  thereby  mahe  a  negative  diagnosis  of  syphilis; 
for  the  same  coitus  that  transmitted  the  chancroid  may  have  transmitted 
syphilis,  the  chancre  of  which  might  not  develop  until  after  the  chan- 

^  Thus  Dnbreuilh  (Jour,  de  med.  de  Bordeaux,  1893,  vol.  xxiii,  p.  573)  has 
reported  an  epidemic  of  chancroids  producing  136  buboes.  Of  these,  27  did  not 
sujipurate;  43  were  incised,  the  pus  was  sterile  to  culture  and  they  healed  rapidly; 
51  became  virulent,  though  sterile  when  incised;  only  3  were  virulent  at  the  time 
of  incision;  and  12,  which  were  open  on  admission  to  the  hospital,  were  all 
virulent, 

^  To  perform  auto-inoculation,  cleanse  a  spot  on  the  outer  side  of  the  patient's 
thigh  with  alcohol;  then  with  a  clean  bistoury  or  pin  wipe  a  little  pus  from  the 
suspected  sore;  twirl  the  point  of  the  instrument  into  the  skin  at  the  point  to 
be  inoculated  just  deep  enough  to  draw  the  most  minute  drop  of  blood,  smear  the 
spot  well  with  the  virus,  and  clap  on  a  vaccination  shield.  A  ' '  take ' '  is  announced 
by  the  appearance  of  a  typical  chancroid  on  the  third  day.  Tliis  should  promptly 
be  destroyed  by  cauterization. 

The  mere  appearance  of  a  pustule  or  an  ulcer  after  inoculation  proves  nothing. 
It  must  be  chancroidal  in  type  to  be  considered  trustworthy  evidence.  If,  after 
inoculation,  thei-e  is  still  some  doubt  of  the  nature  of  the  ' '  take, ' '  its  secretions  may 
lie  examined  for  the  Ducrey  bacillus  with  better  prospect  of  success  than  in  the 
original  sore,  or  the  diagnosis  may  be  confirmed  by  hetero-inoculation  (inoculation 
of  another  person). 


666  CHANCROID 


croid  was  cured,  or  might  develop  on  the  chancroid,  and  be  so  insignifi- 
cant as  to  escape  the  most  careful  scrutiny. 


TREATMENT 

Abortive  Treatment — A  chancroidal  ulcer  not  more  than  three  or 
four  days  old  may  be  completely  destroyed  by  the  application  of  pure 
nitric  acid  after  anesthetization  with  10  per  cent  cocain  solution.  But 
the  opportunity  to  apply  such  treatment  is  extremely  rare.  The  ulcer 
can  only  be  thus  aborted  when  it  is  palpably  very  superficial.  Unless 
every  bacillus  is  reached  and  killed  by  the  acid,  such  cauterization  man- 
ifestly does  more  harm  than  good.  The  presence  of  older  lesions  in 
the  vicinity,  therefore,  contra-indicates  this  treatment. 

Curative  Treatment.  — Three  rules  sum  up  the  routine  treatment  of 
chancroid. 

1.  Establish  the  best  possible  surgical  conditions  by  the  treatment 
of  complications  (see  below). 

2.  Clean  the  ulcers  and  dust  twice  a  day  with  argyrol  crystals.  This 
is  almost  a  specific. 

3.  Always  suspect  old,  rebellious,  or  phagedenic  sores  of  syphilis. 
Treat  them  locally  by  cauterization  with  carbolic  acid  or  silver  nitrate, 
if  mild;  by  the  actual  cautery  (under  general  anesthesia),  if  phage- 
denic. 

Prevention  of  Bubo. — Warn  the  patient  to  avoid  all  violent  exer- 
cise, and  to  walk  about  as  little  as  possible  in  the  hope  of  preventing 
suppurating  bubo.  Watch  the  groins  carefully,  and  with  the  first  sign 
of  peri-adenitis  (matting  together  of  the  glands)  clap  him  into  bed  with 
a  hot-water  bag  on  his  groin. 

Do  not,  under  any  circumstances,  paint  the  groin  with  iodin.  It 
does  no  good  and  causes  irritation  of  the  skin,  so  that,  if  the  bubo  does 
eventually  suppurate  and  burst,  the  surrounding  skin  is  ready  for  inoc- 
ulation. 

Treatment  of  Complications. — Cellulitis  and  suppuration  call  for 
wet  dressings,  rest  in  bed,  elevation  of  the  penis,  and  incision,  secundum 
artem. 

Phimosis,  whether  congenital  or  inflammatory,  is  the  most  annoy- 
ing complication  of  chancroid.  A  chancroid  under  a  tight  foreskin, 
unless  aborted  by  argyrol,  demands  prompt  liberating  incision.  Dorsal 
incision  sometimes  suffices ;  but  a  bilateral  incision  affords  much  more 
satisfactory  access  to  sores  in  the  region  of  the  frenum. 

After  the  chancroids  have  healed  a  secondary  circumcision  is  usu- 
ally required. 

Above  all  things,  do  not  pull  back  a  tight  prepuce.     The  para- 


TREATMENT  667 

phimosis  whicli  will  probably  result  is  not  easy  to  reduce,  and  is  the 
most  fertile  cause  of  gangrene. 

Partial  erosion  of  tlie  frenum  forms  a  pocket  which  is  very  hard  to 
clean.  Tie  a  thread  tightly  around  the  remaining  band,  and  it  will  cut 
through  within  fortv-eight  hours. 

Suppurating  huho  should  be  drained  by  very  small  incisions,  almost 
punctures,  multiple  if  need  be,  followed  by  injection  of  a  10  per  cent 
iodoform-in-vaselin  ointment.  This  injection  is  repeated  every  third 
day  until  the  purulent  discharge  ceases.  It  invariably  prevents  chan- 
croidal ulceration. 


CHAPTEK    LXIX 

GENERAL  CONSIDERATIONS  IN  OPERATING  ON  THE  URINARY 

ORGANS 

The  major  operations  upon  the  urinary  organs  are  often  performed 
upon  patients  whose  kidneys  are  gravely  diseased,  and  whose  constitu- 
tions are  more  or  less  undermined,  both  by  infection  and  by  renal  in- 
sufficiency. The  following  considerations  are  of  importance,  in  the 
order  given : 

Complete  diagnosis. 

Improvement  of  the  kidney  action  and  reduction  of  sepsis. 

Choice  of  anesthetic. 

Choice  of  operation. 
After  the  operation,  the  important  special  considerations  are : 

Facilitating  the  action  of  the  kidneys. 

Drainage  (retained  ureteral  or  urethral  catheter). 


DIAGNOSIS 

The  pathological  conditions  in  the  urinary  organ  of  a  patient  who 
is  about  to  submit  to  operation  are  often  both  multiple  and  complex. 
A  patient  with  an  enlarged  prostate,  for  instance,  may  have  both  stone 
and  tumor  in  his  bladder  (I  once  came  upon  one  of  my  assistants  en- 
deavoring to  do  a  litholapaxy  under  these  circumstances)  ;  or  he  may 
have  a  saccule.  If  so,  the  removal  of  his  prostate  -affords  only  partial 
relief.  Pain  and  blood  seen  issuing  from  a  ureter,  with  an  x-ray  shad- 
ow showing  a  stone  on  that  side  of  the  pelvis,  might  seem  sufficient 
for  a  diagnosis  of  renal  stone  or  ureteral  stone.  So  it  did  in  one  of  my 
cases ;  but  the  stone  was  in  the  appendix  and  had  I  taken  the  trouble  to 
do  a  careful  functional  test  I  should  have  realized  that  it  could  not 
be  in  the  urinary  tract.  When  a  patient  passes  a  great  deal  of  blood 
in  the  urine  and  has  a  very  large  kidney  there  seems  little  question  but 
that  the  blood  comes  from  that  kidney ;  yet  in  one  of  my  cases  that 
had  no  pus  whatever  in  the  urine  this  free  bleeding  came  from  an 
ulcer  on  the  papilla  of  a  tuberculous  kidney  whose  fellow  was  enor- 
mously hypertrophied  but  otherwise  normal.  A  pain  in  the  side  preced- 
ing a  calculous  anuria  would  seem  to  justify  operation  upon  that  kidney. 

668 


PREPARATION  FOR  OPERATION  66Q 

1  once  followed  this  suggestion  and,  altliough  I  came  upon  a  diseased 
kidney,  at  the  post  mortem  examination  the  opposite  kidney  was  found 
acutely  obstructed  by  a  stone  in  the  orifice  of  its  ureter.  Plad  I  operated 
upon  the  other  side  the  patient  would  have  been  saved.  A  patient 
with  advanced  pulmonary  tuberculosis  and  symptoms  of  surgical  renal 
disease  might  be  expected  to  have  a  tuberculous  kidney.  Yet  from  one 
such  patient  I  have  removed  a  kidney  almost  totally  destroyed  by  tumor, 
and  from  a  second  a  kidney  containing  the  largest  stone  I  have  had  to 
deal  with.  The  tests  made  in  this  case  showed  a  pyonephrosis  with 
tubercle  bacilli;  omission  of  the  x-ray  led  to  overlooking  of  this  very 
large  stone.  Such  are  some  of  the  many  pitfalls  which  may  be  avoided 
only  by  employing  before  operation  every  device  to  accomplish  the  most 
complete  diagnosis  possible. 

The  routine  examination  of  every  major  urinary  case  includes  the 
following  items : 

1.  Complete  urinalysis  and  physical  examination. 

2.  Blood  pressure. 

3.  Phenolsulphonephthalein  test. 

4.  Radiography. 

5.  Cystoscopy  and  ureteral  catheterization  with  kidney  function 
test. 

6.  Other  tests,  such  as  pyelography  or  cystography,  as  may  be  sug- 
gested by  the  results  of  the  preceding  examination. 


PREPARATION  FOR  OPERATION 

General  Preparation. — If  the  preceding  examination  has  shown  that 
the  patient's  general  condition  is  such  as  to  permit  operation  and  that 
no  special  contra-indications  exist  the  general  preparation  of  the  patient 
differs  little  from  that  for  any  other  type  of  operation.  A  few  points 
may  be  specified  as.  follows : 

1.  The  patient's  skin  should  always  be  prepared  by  scrubbing,  never 
by  tincture  of  iodin.  This  must  be  the  general  rule  for  hospital  cases 
inasmuch  as  a  great  many  of  them  have  to  do  with  the  genitals,  and  it  is 
quite  impossible  to  clean  the  skin  of  the  scrotum  by  chemicals.  It  re- 
quires a  thorough  scrubbing  after  the  patient  has  been  anesthetized  and 
is  on  the  operating  table. 

2.  The  use  of  morphin  either  before  or  after  operation  is  not  con- 
tra-indicated by  any  renal  condition  with  which  I  am  acquainted.  The 
drug  does  interfere  with  the  activity  of  the  kidney,  but  only  temporarily. 
The  advantage  of  the  use  of  morphin  often  far  outweighs  its  disadvan- 
tages. For  instance,  I  have  at  present  under  my  care  a  patient  who  is 
dying  of  cardiac  decompensation  in  connection  with  a  chronic  pyelone- 


670  GENERAL  OPERATIVE  CONSIDERATIONS 

phritis  due  to  a  stricture  of  the  urethra.  He  recently  passed  but  2 
ounces  in  12  hours ;  he  was  then  given  |  grain  of  morphin,  slept  9  hours, 
and  passed  10  ounces  of  urine  in  the  subsequent  12  hours. 

For  several  years  past  I  have  used  hyoscin  and  morphin  as  almost 
a  routine  preliminary  to  operation. 

3.  Appropriate  pre-operative  treatment  is  required  for  diabetes, 
decompensated  heart  cases,  high  blood  pressure  and  edema,  etc.  Rest 
in  bed  with  appropriate  drugs  and  diet  will  often  put  such  patients 
in  a  condition  in  which  they  can  be  operated  upon.  The  indications  and 
contra-indications  are  in  no  way  special  for  operation  upon  the  urinary 
tract. 

Preparation  of  Patients  with  Urethral  Retention  of  Urine. — The 
pre-operative  problem  presented  by  the  j)atient  with  urethral  retention 
of  urine  has  become  classic  in  the  treatment  of  sufferers  from  pros- 
tatism. But  the  prostatic  is  only  a  type,  though  often  the  most  extreme 
type  of  this  condition.  Urethral  stricture  presents  precisely  the  same 
problem,  so  does  large  vesical  calculus ;  so,  indeed,  do  certain  renal  condi- 
tions with  low  phenolsulphonephthalein  output.  But  the  problem  of 
the  prostatic  summarizes  all  of  these. 

The  preparation  required  by  the  prostatic  depends  upon  the  pre- 
liminary diagnosis;  the  following  rules  may  be  laid  down: 

1.  The  prostatic  should  never  be  operated  upon  while  in  acute  reten- 
tion. This  retention  must  first  be  relieved  by  the  retained  catheter 
or  by  suprapubic  drainage  until  the  patient  has  passed  through  the  acute 
reactionary  congestion  of  the  kidneys  and  the  acute  renal  infection 
which  inevitably  ensue.  This  period  used  to  be  put  at  about  one 
week.  It  is  safer  to  prolong  it  until  all  subjective  evidence  of  acute 
renal  disturbance  such  as  fever,  dry  tongiie  and  disturbed  mentality 
have  disappeared,  and  further  until  the  phenolsulphonephthalein  test 
has  shown  a  recovery  from  the  first  depression,  which  recovery  may 
carry  it  back  to  a  point  even  higher  than  it  was  at  the  time  the  catheter 
was  first  introduced  into  the  patient's  bladder. 

2.  We  are  accustomed  to  consider  absence  of  infection  almost  as 
dangerous  as  the  presence  of  retention.  But  this  is  probably  only 
because  the  absence  of  infection  and  the  presence  of  acute  retention 
is  a  combination  often  seen,  and  an  extremely  dangerous  one.  If  one 
operates  between  attacks  upon  a  patient  with  a  clean  bladder  and  a 
retention  of  no  more  than  3  or  1  ounces  of  urine  no  undue  inflammatory 
reaction  or  failure  of  the  kidneys  may  be  expected  unless  the  phenol- 
sulphonephthalein test  before  operation  is  extremely  low.  But  the 
combination  of  an  uninfected  bladder  and  considerable  retention  is  an 
extremely  dangerous  one.  Prostatectomy  upon  such  patients  results  in 
a  very  high  mortality. 

On  the  other  hand  the  patient  with  a  chronic  retention  and  in  so- 


CHOICE  OF  ANESTHETICS  671 

called  catheter  life  is  the  safest  possible  risk  for  prostatectomy,  unless 
his  heart  or  his  kidneys  are  worn  out. 

The  'Phenolsulphonephthalein  Test. — The  use  of  the  phenol- 
sulphonephthalein  test  as  a  pre-operative  indication  of  the  patient's  con- 
dition is  almost  universal  among  American  urologists  today.  As  has 
already  been  insisted,  however,  the  findings  of  the  test  are  not  absolute. 
If  the  phenolsulphonephthalein  output  in  one  hour  after  intramuscular 
injection  is  as  high  as  25  per  cent  and  the  patient  is  in  no  acute  inflam- 
matory or  retentive  condition,  he  may  be  estimated  a  good  operative 
risk  as  far  as  his  kidneys  are  concerned. 

If  there  is  considerable  retention  or  acute  infection,  however,  this 
must  be  overcome  before  the  phenolsulphonephthalein  assurance  is 
accepted. 

Yet  a  fine  disregard  of  the  findings  of  the  phenolsulphonephthalein 
test  may  be  expected  of  any  accomplished  surgeon.  For  in  some  cases 
the  phenolsulphonephthalein  output  becomes  and  remains  inexplicably 
low.  This  indicates  damaged  kidneys  to  be  sure,  yet  the  damage  of  the 
kidneys  may  not  be  so  great  as  to  prohibit  operation.  If  such  a  patient 
has  neither  subjective  nor  objective  symptoms  of  any  acute  condition, 
if  his  heart  is  reasonably  sound  or  fortified  by  rest  and  digitalis,  if  the 
surgeon  is  skillful  enough  to  perform  his  operation  rapidly,  and  with  a 
minimum  of  hemorrhagic  and  anesthetic  shock,  almost  any  operation 
may  be  performed  in  spite  of  almost  any  failure  of  the  phenolsulphone- 
phthalein test.  As  a  rule  such  cases  should  show  a  low  blood  urea, 
though  curiously  enough  they  may  at  the  same  time  show  a  low  output 
of  urea  in  the  urine. 

Preliminary  Hexamethylenamin. — Although  the  virtue  of  hexa- 
methylenamin  as  a  pre-operative  antiseptic  is  by  no  means  definitely 
determined  it  is  prudent  to  administer  this  in  doses  of  at  least  1  gram 
t.  i.  d.,  for  one  or  two  days  preceding  any  operation  upon  the  urinary 
tract. 

Preliminary  Diuresis. — Along  with  the  hexamethylenamin  it  is 
wise  to  administer  water  to  the  point  of  obtaining  50  or  60  ounces  of 
urine  in  the  24  hours  preceding  operation,  and  of  reducing  the  specific 
gravity  of  this  fluid  to  at  least  1.015.  The  administration  of  water  may, 
however,  be  overdone.  The  routine  administration  of  large  quantities  of 
water  is  likely  to  result  only  in  irritating  the  patient's  bladder  and  in 
(Congesting  the  kidneys  as  well. 

CHOICE  OF  ANESTHETICS 

It  is  futile  to  lay  down  rigid  rules  on  the  subject  of  anesthesia. 
Every  anesthetic  is  dangerous  and  each  surgeon  will  succeed  best  with 
the  anesthesia  to  which  he  and  his  assistants  are  most  accustomed. 


672  GENERAL  OPERATIVE  CONSIDERATIONS 

General  anesthetics  are  said  to  be  better  given  in  this  country  than 
in  Europe.  The  favorite  anesthetic  in  this  country  at  the  present  time 
is  the  gas  oxygen  method  usually  administered  by  the  technic  of  Crile 
and  often  preceded  by  1/200  of  a  grain  of  hyoscin  and  i  of  a  gTain 
of  morphin  one  hour  before  operation.  I  favor  this  preliminary  nar- 
cosis as  being  free  from  danger  and  making  the  subjective  operative 
shock  much  less  for  the  patient;  but  I  have  unfortunately  not  yet 
met  the  ideal  anesthetist  to  administer  gas  and  oxygen  without  admix- 
ture of  ether.  It  has  been  my  experience  that  if  this  anesthetic  is  to  be 
successfully  administered  it  is  best  to  anesthetize  the  patient  with  gas 
followed  by  ether  (the  so-called  ether  induction  method)  and  then  to 
proceed  with  gas  and  oxygen  and  as  little  ether  as  possible.  But  a 
truly  skillful  etherizer  will  do  almost  as  well  as  the  expert  in  gas-oxygen. 

Though  excellent  authorities  can  be  cited  on  either  side,  the  prevail- 
ing surgical  view  today  seems  to  be  that  ether  is  less  disturbing  to  the 
kidney  action  than  chloroform. 

Local  anesthesia  should  be  substituted  for  general  anesthesia 
wherever  the  skill  of  the  operator  with  this  method  permits.  Most 
scrotal  operations  can  be  performed  under  local  anesthesia,  though  for 
inflammatory  conditions  I  still  prefer  ether.  Suprapubic  cystotomy  and 
lithotomy  may  perfectly  well  be  done  under  local  anesthesia  and  several 
surgeons  have  successfully  performed  prostatectomy  by  this  method.  I 
have  not  yet  been  converted  to  it.  Local  anesthesia  is  of  no  value  for 
kidney  operations  excepting  for  the  puncture  of  large  hydronephroses 
or  pyonephroses.  European  surgeons  are  employing  paravertebral  anes- 
thesia for  this  purpose,  and  I  have  performed  one  nephrectomy  by  this 
technic.  I  am  not  convinced  of  its  advantage  over  a  good  general 
anesthetic. 

Sacral  anesthesia  has  also  been  praised  for  operations  about  the 
pelvis.     I  have  had  no  luck  with  it. 

Spinal  anesthesia  I  have  employed  about  200  times  with  1  death 
due  to  anesthetic  and  1  death  possibly  attributed  thereto.  This  method 
of  anesthesia  has  fallen  into  disfavor  because  of  the  great  fall  of  blood 
pressure  induced,  especially  if  the  anesthesia  is  carried  high  enough  to 
permit  an  abdominal  operation.  Eor  minor  procedures  it  is  objection- 
able because  of  the  headache  which  is  so  likely  to  follow  the  spinal 
puncture.  In  the  last  year  or  two  I  have  restricted  its  use  to  difficult 
cystoscopies.    Sacral  anesthesia  may  supplant  it  for  this. 


POSTOPERATIVE  CARE 

The  patient's  most  crying  need  after  operation  is  for  watei  to  pro- 
mote free  diuresis.     This  water  may  be  administered  while  the  patient 


DRAINAGE  673 

is  still  on  the  operating  table  througli  the  stomacli  tube  or  by  bypo- 
dermoclysis,  or  intravenous  infusion.  But  these  methods  have  of  late 
years  been  supplanted  by  Murphy's  drip  method  of  administering  water 
by  rectum.  This  should  be  employed  in  all  major  surgical  cases, 
whether  failure  of  the  kidneys  is  looked  for  or  not.  The  drip  should 
be  kept  up  only  long  enough  to  insure  free  activity  of  the  kidney. 
It  may  usually  be  stopped  in  12  hours  after  operation. 

As  soon  as  the  patient's  stomach  will  hold  it,  the  administration  of 
hexamethylenamin  is  resumed  in  doses  as  high  as  the  patient  can  bear 
and  continued  until  all  danger  of  acute  renal  infection  has  passed.  As 
a  routine  measure  it  is  not  unwise  to  continue  this  drug  for  about  a 
week  after  operation. 

I  believe  in  using  morphin  freely  after  operations,  and  do  not  feel 
that  I  have  ever  seen  any  harm  result  from  this  practice.  The  rest  and 
relief  from  pain  do  far  more  good  than  the  renal  retention  does  harm. 


DRAINAGE 

Drainage  is  provided  for  in  a  special  manner  by  the  operative  tech- 
nic  of  each  procedure  to  be  described. 

The  Retained  Catheter. — One  of  the  most  valuable  ways  of  provid- 
ing drainage  for  the  bladder,  both  before  and  after  operation,  is  by  the 
retained  catheter  (indwelling  catheter,  catheter  tied  in,  catheter  a 
demeure). 

The  retained  catheter  or  sound  is  employed  either  for  dilatation  or 
for  drainage.  For  the  former  purpose,  filiform  bougies  are  tied  into 
the  urethra ;  for  the  latter  purpose,  silk  or  rubber  catheters  are  em- 
ployed. No- metal  instruments  should  he  tied  into  the  urethra^  for  fear 
of  causing  severe  ulceration  of  the  walls  of  the  canal. 

Antisepsis. — Before  introducing  the  retained  catheter,  the  anterior 
urethra  should  be  thoroughly  irrigated  with  a  1 :  4,000  solution  of  per- 
manganate of  potash,  and  the  glans  penis  scrupulously  cleansed  with 
soap  and  water  and  bichlorid. 

The  technic  of  the  retained  catheter  has  been  minutely  explained  by 
Guyon.^     His  rules  may  be  summed  up  as  follows : 

1.  The  instrument  employed  should  be  large  enough  to  permit  h 
free  outflow  of  urine,  and  small  enough  not  to  make  any  pressure  along 
the  canal.  Its  eye  must  be  near  the  end.  Metal  and  olivary  instruments 
are  useless.  The  simple  rubber  catheter  or  woven  catheter  should  be 
employed.^ 

*"LeQons  cliniques,"  1897,  iii,  328. 

'  We  may  add  that  special  forms  of  self-retaining  catheter  are  irritating  to 
the  male  bladder,  though  they  are  favored  for  drainage  of  the  bladders  of  women. 


674 


GENERAL  OPERATIVE  CONSIDERATIONS 


2.  The  instrument  must  be  introduced  so  far  as  to  have  its  eye 
well  within  the  bladder.     When  the  catheter  is  properly  placed  the 
j^m^  urine   flows    continuously   from    it,    drop   by    drop. 

When  the  retained  catheter  proves  irritating  this  is 
usually  because  it  has  been  introduced  too  far  or  not 
far  enough,  and  is  not  draining  the  bladder  properly. 

3.  The  method  of  fixation  is  described  below. 

4.  While  the  catheter  is  to  remain  in  place  the 
penis  should  be  laid  up  over  the  groin,  to  prevent 
ulceration  at  the  penoscrotal  angle. ^ 

5.  Cleanliness  is  insured  by  using  a  clean  cathe- 
ter in  the  first  place,  by  changing  the  catheter  and 
cleansing  it  and  the  urethra  every  five  days,  by  using 
daily  irrigations  of  the  bladder,  by  wrapping  the 
penis  in  a  wet  dressing  of  bichlorid  (1 :  10,000),  and 
hy  using  an  aseptic  urinal.  An  ordinary  glass  bed 
urinal  will  suffice.     A  rubber  tube  is  led  into  it  from 


Fig.   141. — Filiform  Bougie  Tied  On. 

the  catheter,  and  a  little  (1:40)  carbolic  solution 
kept  in  the  vessel.  The  urinal  is  to  be  scoured  and 
boiled  daily. 

When  the  retained  catheter  acts  efficiently  it  re- 
duces urinary  fever  and  septicemia.  When  it  acts 
inefficiently  it  produces  them.  Inefficient  action 
may  be  due  to  plugging  of  the  catheter  by  pus  or 
blood,  to  malposition  of  the  catheter,  or  to  an  idio- 
syncrasy of  the  patient. 

Fixation. — The  female  urethra  is  so  short  that 
an  indwelling  catheter  in  it  must  be  of  the  self- 
retaining  type  (Fig.  140).  Self-retaining  catheters 
are  of  no  value  in  the  male  urethra.  In  the  female, 
the  catheter  is  held  in  place  by  tying  a  number  of 
silk  strings  to  it  as  it  issues  from  the  vulva  and  fixing  these  to  the  pubic 
hairs  in  front,  and  by  means  of  adhesive  strapping  to  the  lateral  gluteal 
creases  behind. 

^  This  is  not  necessary  if  a  soft  rubber  catheter  is  used. 


Fig.  140.  —  Pezzer 
Self  -  retaining 
Catheter. 


DRAINAGfE 


675 


Fixation  in  the  male  varies  according  to  the  instrument  used.  Fixa- 
tion of  a  filiform  may  be  accomplished  by  tying  a  silk  suture  about  it 
as  it  issues  from  the  meatus,  tying  the  ends  of  this  suture  together  at  a 
point  about  1  cm.  distant  from  the  bougie,  and  then  running  the  ends 
about  the  coronary  sulcus  and  tying  them  above  (Fig.  141).  A  catheter 
is,  however,  too  heavy  to  be  held  by  this  method.  It  may  best  be 
retained  by  the  dressing  devised  by  Dr.  Sinclair. 

Two  pieces  of  adhesive  plaster 
are  cut  into  small  rectangles,  of 
which  the  long  diameter  will  just 
surround  the  catheter,  and  the 
short  diameter  is  about  1  cm. 
From  the  long  edge  of  this  rectan- 
gle two  strips  extend  for  about  10 
cm.  and  are  infolded  so  that  they 
will  not  stick.  The  resultant 
product  resembles  a  pair  of 
trousers.  The  rectangles  are  af- 
fixed about  the  catheter  close  to 
the  meatus,  so  that  the  "trouser 
legs"  extend  over  the  body  of  the 
penis  at  four  equal  angles.  The 
shaft  of  the  organ  is  then  sur- 
rounded without  compression  by  a 
band  of  adhesive  plaster  about  2 
cm.  in  width,  the  legs  of  the  cathe- 
ter bands  pulled  down  over  this 
(Fig.  142)  and  fixed  by  means  of 
another  strip  of  adhesive  plaster. 
Before  this  is  made  adherent,  each 
of  the  legs  is  pulled  taut.  Brief 
compression  then  fixes  the  outer 
band  of  adhesive  plaster  over 
these.  The  solidity  of  the  fixation 
is    insured    by    wrapping    a    silk 

string  three  or  four  times  about  the  adhesive  plaster  on  the  catheter  and 
tying  it  tightly. 

Position  of  the  Penis. — If  a  silk  catheter  is  used,  the  penis  must 
lie  over  the  groin ;  otherwise  ulceration  at  the  penoscrotal  angle  will 
result.  If  a  rubber  catheter  is  used,  no  attention  need  be  paid  to  this 
detail,  but  the  end  of  the  catheter  may  be  permitted  to  drop  into  a  urinal 
situated  between  the  patient's  thighs. 

Requisites  for  Success. — In  order  that  the  catheter  shall  work 
properly,  it  is  necessary  that  it  ghould  fit  loosely  but  snugly  in  the 


Fig. 


142. — Sinclair's   Method   of   Fixing 
Retained  Catheter. 


676  GENERAL  OPERATIVE  CONSIDERATIONS 

urethra  (about  size  17  French) ;  that  its  tip  should  remain  in  the  blad- 
der ;  and  that  it  should  be  changed  every  three  to  six  days,  according  to 
the  irritation  it  excites.  While  the  catheter  is  in  place,  the  bladder 
should  be  irrigated  at  least  once  a  day,  and  when  it  is  changed  the 
anterior  urethra  should  be  thoroughly  flushed  with  permanganate 
solution. 

The  catheter  always  excites  a  mild  urethritis,  and  sometimes  great 
protestations  of  pain  from  the  patient;  but  if  the  urine  drips  from  it 
regularly,  it  is  well  to  quiet  the  patient  for  the  first  twenty-four  hours 
by  assurances  and  narcotics,  after  which  his  objections  will  usually 
cease;  but  if  the  bladder  persistently  expels  the  catheter,  or  if  the  pa- 
tient protests  too  loudly,  or  if  fever  results,  it  cannot  be  employed. 


CHAPTEE    LXX 
OPERATIONS    UPON    THE    KIDNEY 

SURGICAL  ANATOMY 

Gross  Anatomy. — Although  familiarity  with  the  minute  anatomy 
of  the  kidney  is  an  essential  part  in  the  equipment  of  every  practitioner, 
be  he  physician  or  surgeon,  it  is  quite  impracticable  to  enter  upon  this 
intricate  subject  here.  A  brief  survey  of  the  gross  anatomy  of  the 
organ  must  suffice.     The  rest  we  leave  to  the  histologist. 

The  kidney  is  ovoidal  in  shape,  flattened  anteroposteriorly,  and 
with  a  deep  notch,  the  hilum,  in  its  inner  border.  The  renal  vessels  and 
nerves  enter  the  organ  through  the  hilum,  the  vein  lying  in  front  of  the 
artery,  while  behind  these  is  the  conical  pelvis,  terminating  below  in 
the  ureter.  The  sinus  of  the  kidney  is  the  irregular  cavity  of  which  the 
hilum  is  the  orifice. 

The  normal  kidney  is  11  cm.  long,  6  cm.  wide,  and  4  cm.  thick.  It 
weighs  from  125  to  200  grams. 

The  kidney  is  closely  surrounded  by  a  fibrous  capsule  sending  fine 
processes  between  the  secreting  tubules.  A  thin,  irregular  layer  of  un- 
striped  muscle  lies  between  the  capsule  and  the  kidney.  When  the  organ 
is  healthy  its  capsule  may  be  readily  stripped  from  it,  but  inflammation 
causes  the  capsule  to  become  adherent. 

A  vertical  section  through  the  kidney  (Fig.  143)  shows  its  secreting 
structure  to  consist  of  two  parts:  an  outer  (cortical)  portion  and  an 
inner  (medullary)  portion,  the  latter  made  up  of  rounded  cones  (pyra- 
mids) whose  apices  (papillae,  mammillae)  project  into  the  sinus  of  the 
kidney;  while  between  the  medullary  pyramids  the  lighter-colored  cor- 
tical portion  of  the  organ  also  abuts  on  the  sinus. 

The  Penal  Aktekies. — The  renal  arteries  are  given  off  one  from 
each  side  of  the  abdominal  aorta,  and  proceed  directly  outward  to  the 
kidney,  lying  behind  the  veins  (the  right  renal  artery  runs  behind  the 
inferior  vena  cava).  As  the  artery  enters  the  hilum  of  the  kidney  it 
divides  into  several  branches,  which  enter  the  cortical  substance  and  are 
thence  distributed  throughout  the  organ.  The  arterial  supply  of  the 
kidney  is  peculiar  in  that  the  vessels  do  not  anastomose.  The  small 
vessels  subdivide  from  the  main  branches  that  enter  between  the  pyr^- 
jaids  and  are  terminal. 

677 


678 


OPERATIONS  UPON  THE  KIDNEY 


Hyrtl  has  shown  that  the  arterial  system  is  divisible  into  two  parts : 
a  more  important  anterior  system,  supplied  by  the  main  branches  of  the 
renal  artery,  and  a  posterior  system,  supplied  usually  by  a  single  branch, 
the  retropyelitic,  that  passes  around  the  posterior  edge  of  the  hilum, 
running  down  upon  the  posterior  surface  of  the  pelvis,  and  sends 
branches  into  the  posterior  part  of  the  kidney.  The  terminal  distri- 
bution of  the  anterior  and  posterior  branches  of  the  renal  artery  is 

neither  definite  nor  fixed, 
but,  generally  speaking, 
the  anterior  branches  sup- 
ply a  little  more  than  the 
anterior  half  of  the  organ. 
Therefore,  in  order  to 
incise  as  few  arterial 
branches  as  possible,  the 
kidney  should  be  opened 
in  a  vertical  line  about  0.5 
cm.  back  of  the  median 
plane  of  the  organ. 

Veins,  IsTerves, 
Lymphatics. — The  renal 
veins  accompany  the  ar- 
teries, lying  in  front  of 
them,^  and  empty  into  the 
inferior  cava.  On  the  left 
side,  the  spermatic,  infe- 
rior phrenic,  and  supra- 
renal veins  are  tributaries 
of  the  renal.  Within  the 
kidney  the  veins  anasto- 
mose freely. 

„      ,,^     ^  „  ^r  The  nerves  of  the  kid- 

FiG.   143. — Frontal   Section  through    the  Kidney,  i      •       i      i 

Pelvis,  and  Calices  (Henle).  A,  branch  of  the  ney  are  derived  through 
renal  artery;  U,  ureter;  C,  calyx;  1,  cortex;  2',  me-  the  renal  pleXUS  from  the 
dulu;  2     boundary  zone;  4,  fat  of  sinus  of  kidney;  5,        ,  ,  ^ 

arterial  branches.  solar  plexus,  the  semilunar 

ganglion,  and  the  lesser 
and  smallest  splanchnic  nerves.  The  spermatic  plexus  is  derived  from 
the  renal  plexus. 

The  lymphatics  accompany  the  blood  vessels  and  empty  into  the 
lumbar  glands. 

Position. — The  kidneys  lie  on  each  side  of  the  spine  in  the  upper 
lumbar  region,  behind  the  other  viscera  and  outside  of  the  peritoneal 

*Nuzurm  {Jour.  A.  M.  A.,  1914,  Ixii,  1238)  has  studied  cases  with  retro-aortic 
left  renal  veins. 


SURGICAL  ANATOMY 


679 


cavity  (Fig.  144).  They  rest  on  the  diaphragm  and  the  psoas  magnus 
and  qnadratus  lumbonim  muscles  between  the  twelfth  dorsal  and  the 
third  lumbar  vertebrae.  Their  upper  extremities  lie  nearer  to  each 
other  than  the  lower,  and  the  internal  borders  face  a  little  downward 
and  forward,  the  outer  borders  upward  and  backward.  The  right  kid- 
ney often  lies  rather 
lower  than  the  left  on 
account  of  the  position 
of  the  liver  above  it. 

The  average  normal 
variation  in  the  posi- 
tion of  the  kidneys  is* 
well  expressed  by  Brew- 
er's ^  statistics  obtained 
in  the  dissecting-room. 
He  found  the  upper 
end  of  the  right  kidney 
opposite  the  eleventh 
rib  in  78  cases,  opposite 
the  twelfth  rib  in  62 
cases,  and  lower  still  in 
9  cases.  The  upper 
end  of  the  left  kidney 
was  opposite  the  tenth 
rib  in  1  case,  opposite 
the  eleventh  in  100 
cases,  opposite  the 
twelfth  in  43  cases,  and 
below  the  >  ribs  in  6 
cases.  Yet  it  must  be 
borne  in  mind  that  dur- 
ing life  the  kidneys 
move  up  and  down  with 
every  respiration,  and 
are  peculiarly  suscepti- 
ble to  downward  dis- 
placement. 

Fatty  and  Fasciai.  Envelope. — The  kidney,  surrounded  by  its 
fibrous  capsule  and  topped  by  the  adrenal,  lies  embedded  in  a  mass  of 
loose  cellular  tissue,  usually  containing  a  considerable  amount  of  fat, 
and  calculated  to  permit  slight  changes  in  its  size  and  position.  This 
fatty  envelope  (perirenal  fat)  quite  fills  the  hollow  of  the  loin,  and  is 
surrounded  and  held  in  place  by  a  distinct  fascia.    This  fascia  has  been 

^Med.  News,  1897,  Ixxi,  129. 


Fig.  144. — Diagram  Showing  Relation  of  the  Viscera 
TO  THE  Parietes;  Posterior  View  (Treves).  S, 
stomach;  L,  liver;  K,  kidney;  SP,  spleen,  R,  rectum. 


680 


OPERATIONS  UPON  THE  KIDNEY 


studied  by  Ziickerkandl,  Gerota,  and  Glantenay  and  Gosset.^  It  com- 
pletely surrounds  the  kidney,  the  suprarenal  capsule,  and  the  perirenal 
fat.  In  front  it  blends  with  the  subperitoneal  fascia,  internally  it  ad- 
heres to  the  vertebral  column,  and  above  to  the  diaphragm.  It  sends  a 
few  fibers  to  the  aponeurosis  of  the  quadratus  lumborum  which  lies 
immediately  behind  it.  It  thus  forms  a  distinct  sac  firmly  anchored  to 
the  diaphragm  and  the  spine.     It  is  everywhere  closed,  except  at  its 


JBLEVEIUE  ua 


LLi.P.      VSfiMCRCKEN  iC 


Fig.  145. — SiTtrATioN,  Direction,  Form  and  Relations  of  the  Kidneys  (Sappey).  1,  1, 
the  two  kidneys;  2,  2,  fibrous  capsule;  3,  pelvis;  4,  ureter;  5,  renal  artery;  6,  renal  vein; 
7,  suprarenal  capsule;  8,  the  liver  Hfted  up;  9,  gall-bladder;  12,  spleen;  14,  abdominal 
aorta;  15,  inferior  vena  cava;  16,  left  spermatic  artery  and  vein. 

lower  extremity,  where  the  posterior  layer  thins  out  and  sends  only  a 
few  fibers  across  to  the  subperitoneal  fascia.  Below  and  behind  this 
fascial  envelope  lies  another  mass  of  fat,  practically  continuous  with  the 
perirenal  fat,  but  distinguished  as  the  pararenal  fat. 

Relations. — Behind,  the  kidney  is  in  relation  with  the  diaphragm 
and  the  psoas  and  quadratus  muscles.  The  last  dorsal  nerve  runs  trans- 
versely between  the  muscles  and  the  perirenal  fascia,  and  the  pleura 
usually  descends  between  the  ribs  and  the  diaphragm  low  enough  to 
cover  the  upper  third  of  the  organ. 

^Gupon's  Annales,   1898,  xvi,   113, 


SURGICAL  ANATOMY  681 

In  front  of  the  right  kidnej  lie  the  duodenum  and  the  ascending 
colon.  A  fold  of  peritoneum  separates  kidney  and  liver  above  the  colon, 
while  lower  down  a  peritoneal  fold  separates  colon  and  duodenum. 

The  left  kidney  is  crossed  by  the  tail  of  the  pancreas  and  lower  down 
by  the  descending  colon,  while  its  upper  portion  is  separated  from  the 
stomach  by  the  lesser  sac  of  peritoneum. 

The  upper  extremity  of  each  kidney  is  capped  by  the  adrenal.  In 
fetal  life  this  is  closely  adherent  to  the  kidney  and  almost  completely 
envelops  it,  but  after  birth  the  adherence  becomes  slight. 

The  Pelvis  of  the  Kidney. — The  pelvis  belongs  anatomically 
to  the  ureter,  of  which  it  is  the  dilated  upper  extremity,  but  surgically 
to  the  kidney,  of  whose  secretion  it  is  the  reservoir  and  in  whose  sur- 
gical disease  it  participates. 

At  the  bases  of  the  renal  pyramids  the  epithelium  of  the  uriniferous 
tubules  joins  with  the  fibrous  covering  of  the  cortex,  the  one  to  form  the 
inner,  the  other  the  outer,  coat  of  a  tube  surrounding  one  or  more  papil- 
lae, and  called  a  calix  (infundibulum).  The  calicos  unite  to  form  the 
pelvis,  an  irregularly  funnel-shaped  pouch  which  protrudes  from  the 
lower  and  back  part  of  the  hilum,  whence  it  runs  downward,  narrowing 
rapidly  to  become  the  ureter  proper  at  a  level  with  the  lower  end  of  the 
kidney. 

The  structure  of  the  pelvis  resembles  that  of  the  ureter  (p.  451). 

The  radiographs,  Figs.  36  and  3Y  and  Plate  V,  illustrate  the  great 
diversity  in  shape  and  size  of  the  normal  kidney  pelvis. 

Generally  speaking,  the  pelvis  splits  up  into  two  main  calices;  the 
upper  one  long  and  thin,  extending  obliquely  upward  to  the  top  of  the 
kidney,  the  lower  one  shorter  and  thicker,  extending  transversely.  Each 
of  these  subdivides  into  several  secondary  calices,  as  the  illustrations 
show.  Manifestly,  therefore,  when  the  kidney  is  incised  for  the  purpose 
of  reaching  the  pelvis,  it  is  wiser,  other  things  being  equal,  to  make 
the  incision  in  the  lower  pole,  both  because  the  lower  calix  is  broader 
and  more  readily  accessible,  and  also  because  it  is  usually  large  enough 
to  admit  the  finger,  which  the  upper  calix  may  not  be. 

Relations  of  the  Vessels  to  the  Kidney  Pelvis. — The  main 
renal  vessels  lie  in  front  of  the  kidney  pelvis  and  extend  from  the  kidney 
in  a  direction  upward  and  inward,  while  the  pelvis,  which  lies  behind, 
drops  almost  directly  downward.  The  only  vessel  of  importance  lying 
behind  the  pelvis  is  the  retropyelitic  artery,  which,  as  stated  above, 
supplies  the  posterior  portion  of  the  kidney.  Inasmuch  as  there  are 
no  internal  anastomoses  in  the  renal  arteries,  division  of  this  artery 
may  occasion  necrosis  of  almost  half  the  kidney.  It  is,  therefore,  im- 
portant to  be  on  the  lookout  for  it  whenever  the  pelvis  is  incised.  It 
usually  skirts  the  upper  edge  of  the  pelvis  within  the  hilum  of  the 
kidney,  so  that,  ordinarily  speaking,  it  is  not  seen. 


682  OPERATIONS  UPON  THE  KIDNEY 

PREPARATION  FOR  OPERATION 

The  preparations  for  operation  upon  the  kidney  are,  generally 
speaking,  those  for  any  major,  general  operation.  The  patient's  general 
condition  should  be  in  the  best  possible  state,  and  the  diagnosis  of  the 
state  of  the  renal  function,  of  the  pathological  condition  of  the  kidneys 
and  of  the  condition  of  the  other  vital  organs,  should  be  most  carefully 
studied. 

The  study  of  the  renal  function  should  be  made  as  previously  laid 
down,  and  it  is  an  excellent  rule  to  perform  radiogTaphy,  ureteral 
catheterism,  and  study  of  the  renal  function  upon  every  patient  whose 
kidney  is  to  undergo  operation.  Under  certain  circumstances  any  or 
all  of  these  tests  may  have  to  be  omitted,  but  one  can  never  tell  before- 
hand which  is  the  case  that  may  absolutely  require  every  diagnostic 
test.  The  recent  confession  of  a  noted  surgeon  that,  in  his  second  series 
of  100  operations  upon  the  kidney,  he  was  mistaken  in  his  diag-nosis 
quite  as  many  times  as  in  the  first  100  cases,  is  but  an  expression 
of  the  gTeat  uncertainty  of  renal  surgery,  which  uncertainty  can  only 
be  lessened  by  familiarity  with  and  constant  application  of  every  device 
for  accurate  diagnosis  before  the  patient  comes  to  the  operating  table. 
(See  Chapter  LXIX.) 

LUMBAR  INCISION 

Position  of  the  Patient. — Eor  such  minor  operations  as  drainage  of 
perirenal  accumulations  of  pus  and  urine,  or  nephropexy,  the  patient 
may  lie  upon  the  abdomen,  since  the  operation  may  be  performed 
through  a  vertical  dorsal  incision,  but  the  only  advantage  of  this  posi- 
tion is  that  it  saves  a  little  time  if  both  kidneys  are  to  be  operated  upon. 
The  almost  universal  custom  is  to  place  the  patient  upon  one  side,  with 
the  hip  and  knee  of  the  under  leg  w-ell  flexed  so  as  to  prevent  the  trunk 
from  tumbling  over,  and  the  knee  and  hip  of  the  upper  leg  extended, 
for  the  purpose  of  retaining  the  balance  and  of  still  further  increasing 
the  size  of  the  lumbar  recess.  To  increase  the  size  of  this  space  still 
further,  and  to  push  the  kidney  upward  and  make  it  more  accessible 
in  the  loin,  it  is  necessary  to  place  some  form  of  pillow  or  bolster 
underneath  the  opposite  loin  of  the  patient.  A  large  sand  bag  or  pillow 
will  serve  this  purpose;  the  Edebohls  kidney  bag  serves  better;  and 
the  appliances  for  this  purpose  fitted  to  all  modern  operating  tables  serve 
best  of  all,  since  these  may  be  raised  or  lowered  and  the  patient,  placed 
upon  the  flat  table,  may  be  raised  into  proper  position  during  the  opera- 
tion, and  dropped  back  upon  the  table  again  when  the  muscles  are  to  be 
sutured.  The  elevation  should  be  such  as  to  put  the  upper  loin  upon 
the  stretch,  but  not  really  to  lift  the  weight  of  the  patient's  body  from 


Fig.  146. — Patient  Lying  on  Side,  Showing  Pkoximity  of  Fkee  Border  of  Ribs  to 

Crest  of  Ilium. 


Fig.  147. — Patient  as  in  Fig.  146,  but  Elevated  by  "Kidney  Support."  Note  how  the 
ribs  are  drawn  away  from  the  iliac  crest.  The  space  between  is  widened  by  the  interval 
included  in  the  Q . 

683 


684 


OPERATIONS  UPON  THE  KIDNEY 


the  hip  and  shoulder  resting  on  the  table.     The  anns  should  be  disposed 
in  front  of  the  patient. 

The  Incision. — Three  incisions  are  in  favor.    In  the  order  of  impor- 
tance they  are: 

The  oblique  incision. 
The  transverse  incision. 
The  vertical  incision. 
The  Oblique  I^ccisigx. — The  surgeon,  standing  behind  the  patient, 
determines  the  position  of  (1)  the  tip  of  the  last  palpable  rib  (^vhich 

may  be  the  eleventh  or  the 
twelfth)  ;  (2)  the  outer 
edge  of  the  mass  of  spinal 
muscles;  and  (3)  the  upper 
border  of  the  iliac  crest. 
The  incision  is  begam  over 
the  rib  at  the  point  where  it 
disappears  under  the  erec- 
tor spinae,  and  carried 
obliquely  down  and  for- 
ward to  pass  two  or  three 
fingers'  breadths  above  the 
upper  edge  of  the  iliac 
crest,  from  which  it  can  be 
carried  still  farther  down 
and  forward  parallel  with 
that  crest,  if  necessary. 
The  incision  should  always  be  long  enough  to  admit  the  whole  hand. 
It  may  be  curved  slightly  with  the  concavity  upward. 

After  incising  the  superficial  tissues,  the  external  oblique  is  reached 
and  divided ;  though  if  an  easy  operation  is  anticipated,  this  muscle  may 
be  thrown  forward  and  the  dissection  continued  between  it  and  the 
spinal  muscles  in  Petit's  triangle.  The  next  plane  reached  is  that  of  the 
internal  oblique  and  transversalis.  If  the  kidney  is  known  to  be  very 
loose,  these  muscles  need  not  be  divided,  but  may  be  separated  on  a 
plane  parallel  with  their  fibers. 

This  muscle-splitting  operation  gives,  however,  a  very  restricted 
field,  and  in  the  great  majority  of  instances  it  is  necessary  to  divide  all 
the  abdominal  muscles  in  line  with  the  external  incision,  the  trans- 
versalis being  split  parallel  to  its  fibers.  If  the  division  is  made  suf- 
ficiently far  back,  the  twelfth  dorsal  ner^^e  is  not  seen ;  if  the  incision 
is  sufficiently  oblique  and  high  above  the  iliac  crest,  the  ilio-ingiiinal 
and  iliohvpogastric  nerves  are  either  not  seen  at  all,  or  are  seen  to  run 
parallel  with  the  incision  and  below  it.  'None  of  these  nerves  should 
be  divided. 


Fig.  148. — The  Oblique  "Kidxet"  Ixcisiox.  .  1,  eos- 
tomuscular  angle;  2,  quadratus  and  spinal  muscles ; 
3,  iliac  crest;  4,  last  dorsal  nerve;  5,  iliohj-pogastric 
nerve;  x,  xi,  xii,  ribs. 


LUMBAR  INCISION  685 

Unless  tlie  kidney  is  very  low  the  incision  sliould  now  be  carried 
upward  along  the  lower  border  of  the  twelfth  rib  (after  making  sure 
that  it  is  the  twelfth  and  not  the  eleventh — otherwise  the  pleura  will 
be  torn).  The  latissimus  dorsi  is  divided,  and  the  rib  freed  from  the 
serratus  posticus  inferior  and  the  erector  spinae  and  finally  from  the 
ligament  of  Henle,  a  fibrous  band  binding  it  down  to  the  first  lumbar 
vertebra.  (These  structures  should  be  incised  at  a  little  distance  from 
the  rib;  otherwise  the  last  dorsal  vessels  will  be  repeatedly  incised. 
They  may  then  be  divided  and  tied  once,  well  away  from  the  rib.) 
With  the  cutting  of  this  ligament  the  rib  will  be  felt  to  spring  away 
from  the  vertel^rae,  thus  greatly  enlarging  the  lumbar  space. 

jSTow  a  mass  of  retroperitoneal  fat  appears  in  the  incision.  This 
is  pushed  down  and  blunt  dissection  made  in  a  backward  and  upward 
direction.  This  brings  the  perirenal  fat  into  the  wound,  surrounded 
by  its  fascial  capsule.  Since  this  fascial  capsule  closely  resembles 
the  peritoneum,  the  surgeon  will  do  well  to  thrust  his  hand  into  the 
incision  along  the  muscles  of  the  back,  and  then,  palpating  forward, 
he  will  feel  the  kidney,  and  be  sure  that  the  tissue  behind  it  is  its  fascial 
capsule.  This  fascial  capsule  is  incised  and  split  longitudinally  by 
the  fingers. 

If  the  kidney  is  quite  loose,  it  may  be  drawn  into  the  wound  by 
catching  the  perirenal  fat  which  now  bulges  out,  and  drawing  it  out, 
both  in  front  and  behind,  while  the  fingers  strip  it  from  the  surface 
of  the  kidney;  but  if  the  kidney  is  adherent,  this  procedure  is  of  no 
avail.  The  hand  must  be  plunged  into  the  loin  and  blind,  blunt  dis- 
section made  with  the  fingers. 

The  first  object  sought  is  to  clear  away  the  upper  pole  of  the  kidney. 
With  the  fingers  close  to  the  organ,  adhesions  are  broken  up  and  the 
perirenal  fat  pushed  aside  until  the  upper  pole  is  reached;  then  the 
fingers  are  swept  around  this,  both  behind  and  before,  until  it  is  quite 
free.  The  upper  pole  is  then  released  and  the  lower  pole  much  more 
readily  freed  in  like  manner.  In  freeing  the  poles  one  should  delay  a 
moment  to  feel  for  aberrant  vessels. 

An  attempt  is  then  made  to  draw  the  kidney  up  into  the  wound, 
either  by  traction  upon  the  perirenal  fat  and  capsule,  or  by  traction 
upon  the  kidney  itself.  If  the  maneuver  is  difficult,  it  may  often  be 
facilitated  by  turning  the  kidney  backward,  inspecting  its  anterior  sur- 
face, and  carefully  incising  adhesions  that  bind  it  to  the  surrounding 
tissues,  pushing  these  away  and  so  advancing,  little  by  little,  until  the 
hilum  is  reached.  The  same  procedure  is  then  employed  for  the  pos- 
terior surface  of  the  kidney,  and  for  its  extremities  as  well.  Finally, 
when  all  adhesions  have  l)een  freed,  the  kidney  readily  pops  out  of  the 
wound,  unless  bound  down  by  considerable  inflammation  about  its 
hilum. 


686  OPERATIONS  UPON  THE  KIDNEY 

The  Tkansvekse  Incision. — This  incision  is  employed  for  the 
removal  of  unusually  large  kidneys.  It  is  carried  parallel  to  the  last 
rib,  and  a  finger's  breadth  below  it  from  the  edge  of  the  spinal  muscles 
to  the  edge  of  the  rectus.  Nephrectomy  is  then  performed  as  described 
on  p.  697. 

The  Vektical  Incision. — The  vertical  incision,  running  directly 
downward  from  the  twelfth  rib  to  the  iliac  crest,  gives  a  field  too  re- 
stricted for  most  operations.  It  may  be  employed  for  nephropexy,  and 
has  the  advantage  of  sparing  the  lateral  and  anterior  abdominal  walls. 

Variations  in  the  Operation. — Many  other  types  of  incision  have 
been  suggested,  but  the  three  mentioned  above  are  the  only  ones  cur- 
rently employed. 

The  oblique  incision  may  be  extended  downward,  for  extraperitoneal 
exploration  of  the  ureter,  as  far  as  the  brim  of  the  pelvis.  If  intra- 
peritoneal complications  are  suspected,  the  peritoneum  may  be  deliber- 
ately incised  and  the  gall-bladder,  the  intestines,  or  even  the  appendix, 
inspected,  while  the  hand  may  be  run  across  for  intraperitoneal  palpa- 
tion of  the  opposite  kidney — a  procedure,  by  the  way,  which  very  rarely 
discloses  anything  worth  knowing.  That  the  opposite  kidney  seems 
sound  on  palpation  is  no  evidence  that  it  has  any  appreciable  functional 
capacity. 

Accidents  in  the  Operation. — The  peritoneum  may  be  torn,  but  this 
is  an  unimportant  accident,  even  if  it  cannot  be  adequately  sutured. 
If  the  kidney  or  the  perirenal  tissues  are  infected,  peritonitis  may  be 
prevented  by  adequate  drainage. 

Injury  to  the  pleura  is  prevented  as  described  above.  Its  occurrence 
is  characterized  by  the  whistle  of  the  air  drawn  in  at  inspiration  and 
the  bubbles  that  appear  in  the  wound  at  expiration.  The  tissues  should 
be  quickly  clamped  and  the  rent  closed  by  suturing  the  diaphragm. 
Other  operative  accidents  relate  to  the  kidney  and  are  mentioned  in  the 
succeeding  chapters. 


THE  TRANSPERITONEAL  INCISION 

Deliberate  transperitoneal  nephrectomy  through  a  vertical  incision 
at  the  outer  edge  of  the  rectus  muscle  is  no  longer  an  approved  opera- 
tion. It  is  employed  only  when  the  surgeon,  ignorant  of  the  precise 
nature  of  the  abdominal  mass  he  is  attacking,  enters  the  peritoneal 
cavity  before  he  recognizes  that  the  kidney  is  the  organ  at  fault.  Under 
these  circumstances  if  the  mass  is  not  infected  it  may  be  attacked  in 
the  way  most  convenient.  If  it  is  infected  the  peritoneal  cavity  may 
be  readily  walled  off  either  by  suturing  the  parietal  peritoneum  and 
then  dissecting  it  laterally  until  the  tumor  is  reached  extraperitoneally, 


THE  TRANSPERITONEAL  INCISION  687 

or  by  making  a  vertical  incision  in  the  peritoneum,  just  lateral  to  the 
ascending  or  descending  colon,  and  suturing  this  layer  of  parietal  peri- 
toneum to  the  inner  edge  of  the  peritoneal  incision  of  the  anterior 
abdominal  wall.  For  a  proper  handling  of  a  renal  growth  under  these 
conditions  it  is  usually  necessary  to  enlarge  the  vertical  incision  by  a 
transverse  one  extending  to  the  loin. 

A  much  more  common  form  of  intraperitoneal  operation  is  that 
which  begins  as  an  extraperitoneal  procedure  in  the  loin,  but  enters  the 
peritoneum  either  accidentally  or  deliberately  on  account  of  difficulties 
in  removing  the  kidney.  Such  an  opening  in  the  peritoneum  need  not 
be  deplored  since  it  often  gives  more  ready  access  to  the  inner  side  of 
the  mass,  and  guarantees  the  safety  of  the  colon  and  the  vena  cava. 
The  intestines  are  simply  walled  off,  and  the  operation  proceeds  in  the 
usual  manner  as  described  on  page  (594. 


CHAPTEE   LXXI 
OPERATIONS  UPON  THE  KIDNEY  (Continued) 


NEPHROTOMY 

The  Operation. — The  kidney  is  laid  bare  through  the  oblique  lum- 
bar incision  in  the  manner  described  above. 

The  vascular  pedicle  is  then  compressed  ^  by  means  of  a  long  intes- 
tinal clamp  with  blades  protected  by  rubber 
tubing.  In  placing  the  clamp,  care  should  be 
taken  to  avoid  the  ureter,  and  for  this  reason 
it  is  better,  if  possible,  first  to  free  the  ureter 
from  the  mass  of  the  renal  pedicle  and  then  to 
place  the  clamp.  The  kidney  is  now  incised 
according  to  the  indications  of  the  particular 
case  in  question.  Other  things  being  equal, 
the  incision  should  always  be  made  parallel  to 
the  long  axis  of  the  kidney  and  preferably 
about  5  mm.  (^  inch)  posterior  to  its  median 
line,  since  this  is  the  region  that  contains  least 
blood  vessels.  Unless  there  is  some  special 
indication  for  opening  the  superior  calyx,  the 
best  incision  is  that  devised  by  Albarran : 


With  a  phange  of  the  bistouiy  to  the  depth  of 
3  cm.,  the  surgeon  incises  the  convex  border  of  the 
kidney  5  mm.  back  on  its  posterior  surface.  The 
incision  should  begin  2.5  cm.  above  the  junction  of 
the  middle  and  inferior  third  of  the  kidney,  and  is 
prolonged  for  an  equal  distance  below  that  point. 
Separation  of  the  wound  surfaces  exhibits  the  sec- 
tion of  the  gTay  mucous  membrane  of  the  inferior 
calyx,  which  has  been  opened.  This  opening  is  en- 
larged with  the  scissoi-s  sufficiently  to  admit  the 
finger  without  tearing  the  kidney  tissue.  It  may  be 
enlarged  from  end  to  end  of  the  kidney  if  necessarj'. 


Fig.  149. — Nephrotomy  In- 
cision. 


^It  has  been  demonstrated  (cf.  Trans.  Am.  Assn.  Gen.-Urin.  Surg.,  1909,  vol. 
iv)  that  compression  of  the  renal  pedicle,  especially  by  instruments,  causes  anuria 
which  may  last  many  hours.  But  Eisendrath  and  Straus  (Jour.  A.  M.  A.,  1910,  Iv,. 
2286)  have  shown  that  the  vessels  may  be  occluded  with  safety  for  half  an  hour. 

688 


NEPHROTOMY  689 

The  "silver  wire"  method  of  nephrotomy  is  the  following:  A  long, 
blunt  slightly  curved  needle  armed  with  a  stout  silver  wire  is  plunged 
into  the  kidney  pelvis  just  at  the  lowest  point  of  the  posterior  lip  of 
the  hilum,  pushed  up  to  the  tip  of  an  adjacent  calyx  and  so  out  through 
the  dorsum  of  the  kidney,  just  behind  its  median  line.  The  points  of 
entrance  and  exit  are  then  joined  by  using  the  wire  as  a  Gigli  saw.  The 
needle  is  then  re-introduced  and  brought  out  at  the  uppermost  calyx 
and  the  kidney  laid  open  from  end  to  end.  This  method  was  expected 
to  minimize  the  resultant  hemorrhage,  but  it  does  not  seem  to  have 
come  into  very  general  use. 

The  finger  is  then  introduced  into  the  pelvis  of  the  kidney,  whence 
it  can  be  passed  well  up  into  the  superior  calyx  and  the  whole  interior 
of  the  organ  be  explored,  counterpressure  being  made  from  without.  If 
there  is  question  of  the  permeability  of  the  ureter  or  of  the  presence  of 
stone  in  that  duct,  a  ureteral  catheter  is  passed  down  into  the  bladder. 
The  catheter  must  pass  at  least  35  cm.  before  one  can  be  sure  that  it  has 
actually  entered  the  bladder. 

This  investigation  is  sufficient  to  disclose  stone  in  the  urinary  pas- 
sages, but  not  to  determine  absolutely  the  presence  of  such  a  lesion  as 
an  ulcerated  papilla  or  a  very  small  neoplasm.  If  this  is  suspected,  but 
the  pre-operative  diagnosis  has  not  been  absolute,  the  kidney  may  be 
split  from  end  to  end  and  carefully  examined. 

Suture  of  the  Kidney — If  the  kidney  is  known  to  be  uninfected, 
it  may  be  sutured  without  drainage.  If  infection  is  known  to  exist,  or 
is  feared,  it  should  be  sutured  around  a  small  rubber  drainage-tube.^ 

To  close  the  kidney  incision,  heavy,  plain  catgut  sutures  should  be 
passed  through  and  through  on  a  large,  curved  needle,  in  such  a  way  as 
to  penetrate  to  the  depth  of  the  wound.  These  sutures  should  be  placed 
about  1  cm.  (|  inch)  apart.  After  they  have  been  placed  the  pressure 
on  the  renal  pedicle  is  released,  the  two  edges  of  the  wound  pressed 
tightly  together,  and  the  sutures  tied  firmly  enough  to  control  hemor- 
rhage but  not  tight  enough  to  cut  through  the  parenchyma.  If  heavy 
catgut  is  not  at  hand,  a  doubled  strand  of  light  catgut  may  be  used  for 
each  suture.  Between  each  of  these  deep  sutures  the  line  of  incision 
is  then  further  closed  by  the  addition  of  a  superficial  suture  which  pene- 
trates only  about  1  cm.  into  the  kidney.  The  kidney  is  then  returned 
to  its  place  in  the  loin,  a  small  drainage-tube  inserted  down  to  the 
kidney,  and  the  abdominal  wound  sutured. 

A  second  tube  is  then  introduced  down  to  the  kidney  to  drain  the 
perinephritic  space,  and  the  parietes  closed  in  layers. 

Postoperative   Treatment. — The  only  special   requirement  is  that 

the  tube  in  the  kidney  be  left  in  place  until  all  hemorrhage  has  ceased — 

^  Cunningham  has  shown  that  in  dogs  postoperative  anuria  lasts  much  longer 
if  the  kidney   is   sutured   than   if   drainage    is   employed. 


690  OPERATIONS  UPON  THE  KIDNEY 

at  least  three  days.     If  the  ureter  is  not  obstructed  the  urinary  fistula 
will  heal  within  the  week. 

Postoperative  Complication — The  only  peculiar  postoperative  com- 
plication is  hemorrhage.  Although  the  hemorrhage  resulting  from 
incision  of  the  kidney  is  alarming  to  the  unaccustomed  surgeon,  it  may 
be  thoroughly  controlled  by  compression  of  the  pedicle  and  by  the  subse- 
quent suture  of  the  organ,  unless  the  kidney  is  chronically  inflamed; 
but  prolonged  chronic  nephritis  produces  changes  in  the  organ  which 
make  it  bleed  profusely  and  make  this  bleeding  very  difficult  to  stop. 
In  not  a  few  instances,  postoperative  hemorrhage  has  either  carried  off 
the  patient  or  called  for  immediate  secondary  nephrectomy  under  most 
trying  circumstances.  For  this  reason  pyelotomy  is,  whenever  possible, 
preferable  to  nephrotomy. 

PYELOTOMY 

The  kidney  is  exposed  and  liberated  as  usual.  After  it  has  been 
brought  up  into  the  loin,  palpation  of  the  region  immediately  beneath 
its  lower  pole  along  the  peritoneum  reveals  the  cordlike  ureter.  The 
fascia  is  stripped  from  the  posterior  surface  of  the  upper  part  of  the 
ureter,  leaving  it  attached  in  front  to  the  peritoneum,  and  the  fascia 
is  also  stripped  from  the  posterior  surface  of  the  pelvis  of  the  kidney, 
care  being  taken  to  avoid  the  retropyelitic  artery.  The  pelvis  is  now 
incised  in  a  line  radiating  from  the  mouth  of  the  ureter  toward  the 
hilum  of  the  kidney.  This  incision  is  made  large  enough  to  admit  the 
little  finger  of  the  surgeon,  with  which  the  interior  of  the  cavity  of  the 
pelvis  is  then  explored.  Through  this  same  incision  stones  may  be 
extracted  and  a  ureteral  probe  may  be  passed  down  into  the  bladder. 

The  wound  in  the  pelvis  is  closed  by  fine  catgut  sutures  through 
and  through.  There  is  rarely  any  need  to  drain  the  pelvis,  but  this  may 
be  done  by  means  of  a  small  catheter  without  fear  of  resulting  fistula. 
A  drainage  tube  is  always  left  in  the  perinephritic  space. 

Wounds  of  the  pelvis  of  the  kidney  may  be  expected  to  heal  by  first 
intention,  if  properly  sutured,  but  a  tube  should  always  be  run  down 
to  the  site  of  the  suture  for  fear  of  a  break.  Urinary  fistula  from  the 
pelvis  is  not  likely  to  continue  for  more  than  two  weeks.  Healing  may 
be  hastened  by  the  indwelling  ureter  catheter. 

NEPHROPEXY  AND  DECAPSULATION  OF  THE  KIDNEY 

The  Operation — The  methods  of  performing  nephropexy  are  in- 
numerable.^    The  essentials  to  a  good  operation  are: 

(1)  All  of  the  perirenal  fat  between  the  kidney  and  its  fascial  en- 
*Luzior  (*'Dc  la  Nephropexie, "  Paris,  1913)  has  described  51  methods. 


NEPHROPEXY  AND  DECAPSULATION  691 

velope  should  be  removed,  in  order  that  the  kidney  may  form  adhesions 
with  the  parietes  which  shall  hold  it  tightly  in  place;  (2)  the  kidney 
should  be  fixed  in  such  a  way  that  its  position  shall  be  as  normal  as  pos- 
sible, its  ureter  and  vessels  not  kinked,  and  itself  held  as  high  as  pos- 
sible up  under  the  ribs;  (3)  the  sutures  by  which  the  kidney  is  held 
should  not  so  restrict  its  mobility  that  its  vessels  may  become  kinked 
after  operation;  (4)  sutures  should  not  pass  through  the  kidney  tissue 
itself,  but  the  organ  should  be  held  in  place  by  sutures  passed  through 
its  capsule. 

Edebohls's  Opekation. — The  method  of  Edebohls  is  the  one  now 
almost  universally  employed.  The  operation  was  performed  by  Ede- 
bohls through  a  vertical  incision;  but  the  oblique  incision  may  be  em- 
ployed. The  perineal  fascia  is  then  incised  and  pulled  well  up  into 
the  wound,  the  fat  separated  from  the  kidney  before  and  behind  and 
carefully  excised,  leaving  only  the  fascial  capsule  surrounding  the 
kidney. 

Decapsulation. — The  kidney  is  then  decapsulated  as  follows: 

A  small  nick  is  made  in  the  capsule  in  the  median  line  near  the 
lower  pole.  A  grooved  director  is  passed  through  this  incision  between 
the  capsule  and  the  kidney,  and  upon  it  the  capsule  is  slit  from  one 
pole  to  the  other  along  the  convex  border.  Each  edge  of  this  incised 
capsule  is  then  freed  from  the  surface  of  the  kidney  by  blunt  dissection. 
Two  suspension  sutures  are  then  placed  through  the  capsule  at  its  point 
of  reflection  from  the  kidney,  without  penetrating  the  kidney  tissue. 
The  kidney  is  then  replaced  in  the  loin  and,  if  necessary,  a  little  separa- 
tion is  made  of  the  tissues  at  the  upper  end  of  the  kidney  recess,  in 
order  to  permit  it  to  pass  freely  up  under  the  ribs.  Either  before  or 
after  the  kidney  is  replaced,  the  pelvis  and  ureter  are  carefully  inspected 
to  see  that  they  are  not  compressed  or  kinked  by  adhesion  to  the  lower 
pole  of  the  kidney.  The  suspension  sutures  attached  to  the  kidney  cap- 
sule are  then  passed  through  appropriate  portions  of  the  parietal  muscles 
and  tied. 

According  to  the  original  Edebohls  method,  the  sutures  were  of  silk- 
worm gilt,  and  were  carried  up  through  the  skin  of  the  loin  to  be  cut  and 
withdrawn  after  healing  had  taken  place ;  but  it  seems  preferable  to 
employ  chromic  gut  and  to  bury  the  sutures.  In  tying  the  sutures,  one 
must,  of  course,  be  careful  to  tie  the  ends  of  each  loop  to  each  other. 


NEPHROSTOMY 

^N'ephrostomy  is  an  operation  upon  the  kidney  for  the  purpose  of 
deflecting  the  urine  through  the  loin  for  a  greater  or  shorter  leng-th  of 
time. 


692  OPERATIONS  UPON  THE  KIDNEY 

Nephrostomy  of  Calculous  Anuria. — The  object  of  this  operation 
is  to  drain  the  kidney  rather  than  to  remove  the  calculus.  Watson  urged 
the  performance  of  simultaneous  double  nephrostomy  for  this  condi- 
tion, and  if  the  condition  of  the  other  kidney  is  doubtful,  this  is  the 
operation  of  choice.  On  account  of  the  patient's  precarious  condition, 
the  operation  should  be  made  as  brief  as  possible,  and  if  any  difficulty 
is  experienced  in  finding  or  removing  a  calculus,  this  should  be  deferred 
to  a  subsequent  operation. 

Nephrostomy  for  Nephritis. — For  chronic  nephritis  the  operation 
of  decapsulation  is  commonly  preferred  to  that  of  nephrostomy,  since  it 
achieves  approximately  the  same  ends  without  destroying  any  of  the 
renal  parenchyma.  If  nephrostomy  and  decapsulation  are  performed 
at  the  same  operation,  care  must  be  taken  to  leave  enough  capsule  along 
the  convex  border  of  the  kidney  to  hold  the  sutures,  for  these  will 
otherwise  tear  through  the  soft  parench^Tiia  (Fig.  15C). 

Nephrostomy  for  Hydronephrosis — Operation  upon  a  hydrone- 
phrotic  kidney  is  always  undertaken  for  the  purpose  of  relieving  the 
obstacle.  If  this  cannot  be  done,  and  the  condition  of  the  opposite  kid- 
ney is  doubtful,  it  may  seem  wise  to  perform  nephrostomy;  but  if  the 
opposite  kidney  is  in  good  condition  and  the  ureteral  obstruction  cannot 
be  relieved,  it  is  wiser  to  remove  the  dilated  kidney. 

Nephrostomy  for  Pyonephrosis. — AYhen  operating  upon  pyonephro- 
sis in  a  patient  whose  opposite  kidney  is  in  a  condition  of  doubtful 
vitality,  or  known  to  be  gi'avely  diseased,  nephrectomy  cannot  be  per- 
formed. 

Albarran  advises  that  the  fatty  capsule  should  only  be  partly 
stripped  away  from  the  kidney,  in  order  to  avoid  the  possibility  of  pock- 
eting of  pus.  The  incision  into  the  kidney  itself  is  made,  if  possible, 
over  a  soft  spot  where  the  parenchyma  is  thin.  The  finger  explores  the 
interior  of  the  pelvis,  extracts  any  calculi  that  are  found  there,  and 
opens  badly  draining  pouches  freely  into  the  general  cavity  of  the 
pelvis.    The  parenchyma  is  then  sutured  about  a  drainage  tube. 

The  kidney  is  drained  until  the  patient's  condition  shall  have 
considerably  improved,  when  a  secondary  nephrectomy  may  be  per- 
formed. 

To  close  the  operation,  the  lips  of  the  kidney  incision  are  partially 
sutured,  while  the  remainder  of  the  kidney  incision  is  sutured  to  the 
muscles  of  the  loin,  in  order  to  prevent  pocketing  of  pus.  Rubber-tube 
drainage  is  required.  If  the  perirenal  fat  has  been  torn  away  freely 
from  the  kidney,  extrarenal  drainage  must  be  provided  as  well. 

The  tubes  are  left  in  the  kidney  so  long  as  pus  in  any  quantity  con- 
tinues to  drain  through  them. 

Nephrostomy  for  Tuberculosis — This  is  an  operation  to  be  em- 
ployed only  as  a  last  resort,  when  both  kidneys  are  known  to  be  gravely 


Fig.  150. — Nephrotomy  with  Decapsulation.  A  section  of  the  capsule  is  preserved  to 
hold  the  kidney  sutures.  The  remainder  is  turned  back  and  caught  in  a  suspension 
suture  for  nephropexy.     (After  Albarran.) 


Fig.  151. — Restbicted  Liberation  of  Perikenal,  Fat  in  NEPHitosTOMY  for  PyoNEPHROSig. 

(After  Albarran.) 

693 


694  OPERATIONS  UPON  THE  KIDNEY 

affected  with  tuberculosis,  and  one  of  them  is  causing  an  active  sepsis. 
The  drainage  must  be  made  permanent. 

Nephrostomy  Preliminary  to  Operation  upon  the  Bladder. — In 
Watson's  operation  for  drainage  of  the  kidney  preliminary  to  removal 
of  the  bladder,  the  surgeon's  object  is  not  to  make  a  fistula  that  will 
soon  close,  but  to  make  one  that  will  remain  permanently  open. 

The  only  difference  between  the  ordinaiy  nephrotomy  and  the  operation 
by  which  a  permanent  drainage  of  the  kidney  is  arranged,  consists  in  attaching 
the  edges  of  the  renal  incision  to  those  of  the  lumbar  wound.  This  is  done  by 
placing  a  row  of  mattress  sutures  on  either  side  of  the  incision  .  .  .  after  which 
the  kidney  and  lumbar  incisions  are  brought  together  by  another  row  of  sutures, 
thus  closing  them  around  the  drainage  tube.  The  latter  is  at  first  held  in  place 
by  a  stitch  passed  through  it  and  through  the  skin  at  the  point  at  which  the  tube 
emerges  from  the  surface.     (Watson.) 

Apparatus  for  Drainage. — Whenever  nephrostomy  is  done,  urine, 
or  urine  and  pus,  run  from  the  wound  in  large  quantities  and  often  for 
a  considerable  time.  It  is,  therefore,  necessary  to  provide  the  patient 
with  an  apparatus  that  will  dispose  of  this  outflow  while  he  is  moving 
about. 

A  patient  of  mine  is  now  wearing  a  silver  tube,  to  which  is  attached 
a  silver  disk  3  inches  in  diameter,  to  rest  against  the  skin,  while  the 
end  of  the  tube  is  turned  down  at  a  right  angle,  and  from  it  a  short 
rubber  tube  leads  into  a  leg  urinal.  For  certain  cases,  the  apparatus 
of  Watson  may  be  more  convenient. 


NEPHRECTOMY 

There  aTe  three  types  of  total  nephrectomy :  the  one  applicable 
to  all  cases  usually  encountered,  excepting  tumors ;  the  second  ap- 
plicable to  very  large  kidneys,  whatever  their  nature;  the  third  em- 
ployed for  the  removal  of  malignant  neoplasm.  The  first,  or  usual 
type  of  nephrectomy,  is  performed  as  follows: 

The  kidney  is  exposed  and  brought  into  the  wound  in  the  usual 
manner,  the  ureter  is  then  identified  running  down  from  the  hilum 
of  the  kidney  against  the  peritoneum.  It  is  readily  liberated  by  blunt 
dissection  or  one  or  two  strokes  of  the  knife,  doubly  clamped  and  divided 
by  the  actual  cautery.  If  the  ureter  is  tuberculous  as  much  of  it  is 
removed  as  possible.  The  stump  is  then  ligated,  the  clamp  removed, 
the  tip  once  again  touched  with  the  cautery,  and  dropped  back  into 
the  wound. 

The  surgeon  next  turns  his  attention  to  slowly  and  methodically 
clearing  the  renal  vascular  pedicle  of  fat  and  fascia.  If  the  pedicle  is 
uninflamed  this  may  readily  be  done  and  the  individual  vessels  may 


NEPHRECTOMY 


695 


even  be  separately  cauglit  and  ligated  before  they  are  cut.  But  if  the 
fascia  of  the  pedicle  has  become  infiltrated  as  the  result  of  prolonged 
suppuration  in  the  kidney  it  may  be  difficult  either  to  separate  the 
pelvis  of  the  kidney  behind  or  the  surrounding  fascia  from  it  on  all 
sides.  A  persistent  but  gentle  effort  to  clear  the  pelvis  shovild  always 
be  made^  for  if  this  is  not  cleared  before  the  clamps  are  applied  to  the 
pedicle  a  piece  of  its  mucosa  may  be  included  in  the  stump  and  en- 
courage subsequent  fistula,  especially  if  it  be  tuberculous.  After  clear- 
ing the  pedicle  as  much  as  possible  it  is  clamped  from  above  down- 


FiG.  152. — Nephbectomy.     (After  Albarran.) 


ward  in  order  that  the  renal  artery  may  be  firmly  caught  in  the  heel 
of  the  clamp.  The  kidney  is  then  tilted  backward  and  the  pedicle  cut 
away  between  it  and  the  clamp.  If  the  kidney  is  tuberculous  one 
should  fill  the  wound  with  large  gauze  pads  before  cutting  the  pedicle 
since  the  blood  effused  may  well  be  loaded  with  tubercle  bacilli  as  the 
result  of  the  manipulation  of  the  organ. 

Ligature  of  the  pedicle  is  usually  the  one  difficult  problem  of 
nephrectomy,  for  the  clamp  holds  the  tissues  of  the  pedicle  so  spread 
out  that  a  ligature  tied  on  the  vessels  near  the  clamp  will  frequently 
slip  from  them  when  this  is  removed.  This  may  be  avoided  by  trans- 
fixing the  pedicle  towards  its  lower  part  (so  as  surely  to  avoid  the 
artery)  and  tying  it  in  two  sections.  Over  this  ligature  a  second  liga- 
ture is  then  applied  and  its  ends  knotted  once,  tension  being  made  upon 


696 


OPERATIONS  UPON  THE  KIDNEY 


them  as  the  clamp  is  taken  off.  One  will  immediately  feel  the  tissues  of 
the  pedicle  shrink  within  the  ligature  which  is  then  pulled  tight  and 
the  second  knot  fastened.  Mayo  ^  whenever  possible  puts  two  clamps 
on  the  pedicle  and  places  his  first  ligature  proximal  to  the  proximal 
clamp,  ties  it  loosely,  removes  the  clamp,  and  ties  it  tightly  in  the 
groove  made  by  the  clamp.  Even  this  type  of  ligature  should  be  forti- 
fied by  a  second  piece  of  catgut  before  the  second  clamp  is  removed. 

But  some  pedicles  are  so  thickened  and  shortened  by  inflammation 
that  it  is  truly  prudent  not  to  waste  time  in  endeavoring  to  ligature 

them  in  any  of  the  above  methods.  Much 
time  may  be  wasted  in  the  effort  to  re- 
move the  clamp  and  in  the  end  the  sur- 
geon may  well  find  that  he  has  four  or  five 
clamps  left  on  his  pedicle  instead  of  one, 
and  this  in  a  case  that  is  likely  to  be  espe- 
cially sensible  to  loss  of  blood  and  pro- 
longed anesthesia.  I  deliberately  leave 
the  clamp  on  such  pedicles  which  used  to 
constitute  about  half  and  now  constitute 
one  in  five  of  the  nephrectomies  I  per- 
form. The  clamp  should  be  removed  on 
the  fourth  day.  I  have  left  clamps  on  at 
least  twenty  cases  and  have  never  seen  any 
hemorrhage  at  the  time  of  their  removal 
(though  I  have  taken  many  of  them  off  on 
the  third  day)  with  the  exception  of  one 
case  whose  renal  vein  had  been  torn.  In 
this  instance  I  opened  the  clamp  on  the 
third  day  and  a  sharp  hemorrhage  ensued.  I  reclosed  the  clamp  and 
the  hemorrhage  stopped.  Two  days  later  the  same  performance  was 
repeated,  but  on  the  seventh  day  the  opening  of  the  clamp  was  not  fol- 
lowed by  bleeding,  and  it  was  safely  removed. 

Subcapsular  Nephrectomy. — It  may  be  impossible  to  liberate  a 
densely  adherent  pyonephrotic  kidney  from  its  bed  without  repeatedly 
tearing  its  fibrous  capsule.  In  this  event  the  easiest  way  to  free  the 
kidney  is  deliberately  to  decapsulate  it.  Traction  on  the  kidney  then 
turns  the  capsule  inside  out,  shrouding  the  ureter  and  vessels  (Fig.  153). 
The  circumcision  of  this  capsule  close  to  the  hilum  brings  the  true  ped- 
icle into  view. 

Disposition  of  the  Tuberculous  Ureter.— The  total  removal  of  the 

ureter  with  the  kidney  for  tuberculosis  is  an  operation  that  still  proves 

tempting  to  many  surgeons.     The  ureter  is  obviously  tuberculous ;  hence 

its  total  removal  seems  indicated.     But  total  removal  in  the  sense  of 

^Jour.  A.  M.  A.,  1915,  Ixiv,  953, 


Fig.  153. — Showing  How  the 
True  Pedicle  Is  Obscubed  by 
THE  Fibrous  Capsule  in  Sub- 
capsular Nephrectomy.  (Af- 
ter Albarran.) 


NEPHRECTOMY  FOR  LARGE  KIDNEYS  697 

removing  all  the  tuberculosis  in  the  ureter  and  the  bladder  beyond  is 
never  contemplated  and  the  clinic  has  shown  that  the  stump  of  the 
ureter  will  usually  take  care  of  itself.  Exceptionally  it  opens  up  and 
discharges  urine  from  the  bladder  back  into  the  wound  (I  have  only 
once  seen  this  happen)  and  Mayo  states  that  about  5  per  cent  of  tuber- 
culous ureters  should  be  removed  because  they  are  dilated  above  a 
stricture. 

I  have  never  removed  a  tuberculous  ureter,  nor  have  I  ever  seen  the 
ureter  become  cystic  after  nephrectomy  as  a  result  of  accumulation  of 
its  own  secretions  within  it. 

Such  a  ureteral  cyst  has,  however,  been  encountered  a  number  of 
times  and  required  preliminary  drainage  and  later  excision  of  the  sac. 

Drainage — Mayo  believes  that  by  filling  the  loin  with  saline  solu- 
tion in  order  to  displace  the  air  in  the  wound,  and  suturing  the  wound 
tightly  a  fistula  is  less  likely  to  follow  nephrectomy  for  tuberculosis  than 
if  drainage  is  employed.  After  following  this  technic  in  perhaps  20 
cases,  I  cannot  see  that  it  has  diminished  the  number  of  postnephrec- 
tomy  fistulae.  It  seems  quite  as  satisfactory  to  treat  the  tuberculous 
nephrectomy  wound  quite  like  any  other  loin  wound  by  drainage  with  a 
small  tube. 

NEPHRECTOMY  FOR  LARGE  KIDNEYS 

Neoplasms  require  a  special  type  of  nephrectomy  to  be  described 
below.  ISTephrectomy  for  large  tumors  other  than  neoplasm  differs  from 
the  operation  described  above  chiefly  in  that  the  incision  employed 
should  be  transverse  rather  than  oblique  with  a  little  hook  up  over  the 
twelfth  rib  where  it  is  covered  by  the  erector  spinae  muscle.  The  rib  is 
freed  as  usual  and  the  transversalis  and  other  abdominal  muscles 
divided  up  to  the  edge  of  the  rectus,  the  line  of  incision  being  about  two 
fingers'  breadth  below  the  tip  of  the  last  rib. 

This  may  be  still  further  enlarged  if  necessary  by  a  vertical  inci- 
sion at  its  anterior  extremity.  The  kidney  is  freed  as  usual  and  if 
there  is  much  perinephritis  on  its  anterior  surface  there  is  no  objection 
whatsoever  to  opening  the  peritoneal  cavity,  walling  off  the  intestines, 
removing  a  section  of  the  peritoneum  adherent  to  the  anterior  surface 
of  the  tumor,  but  carefully  dissecting  the  colon  free  with  due  respect  for 
its  vascular  supply. 

Performed  through  a  large  incision  in  this  manner  the  operation 
presents  singularly  few  difficulties.  Its  one  grave  complication  is  tear- 
ing of  the  vena  cava.  I  have  twice  torn  the  cava,  losing  one  patient 
at  the  end  of  twenty-four  hours  by  hemorrhage,  and  saving  the  othet 
by  a  lateral  clamping.  If  the  wound  is  below  the  renal  pedicle,  as  ifi 
usually  the  case,  the  cava  may  be  ligatured ;  but  as  a  rule-  it  may  bo 


698  OPERATIONS  UPON  THE  KIDNEY 

closed  by  suture  or  by  lateral  clamping.  But  there  is  actually  no  excuse 
for  wounding  this  vessel.  The  surgeon  should  remember  that  it  is  often 
drawn  up  over  the  kidney,  covering  its  anterior  surface  almost  up  to 
the  point  of  contact  with  the  colon.  With  this  in  mind  one  may  avoid 
the  cava  by  freeing  the  colon  gently  toward  the  lower  pole  of  the  kidney, 
then  identifying  the  great  vessels  and  following  these  up  over  the  ante- 
rior surface  of  the  tumor.  One  need  scarcely  add  that  this  danger  only 
refers  to  the  right  kidney. 


NEPHRECTOMY  FOR  NEOPLASM 

The  principles  of  this  operation  diifer  from  those  of  ordinary 
nephrectomy  in  two  ways : 

1.  The  perirenal  fat  must  be  removed  with  the  kidney  unless  we 
are  to  expect  regional  recurrences. 

2.  The  veins,  not  only  those  of  the  pedicle,  but  also  those  covering 
the  surface  of  the  tumor  must  be  ligated  before  the  tumor  itself  is  much 
disturbed  for  fear  of  venous  embolism. 

In  order  to  fulfill  these  two  indications  a  large  incision  and  early' 
ligature  of  all  vessels,  including  thos'^  of  the  pedicle,  are  of  first  impor- 
tance. If  the  kidney  is  not  more  than  twice  its  normal  size  it  may  be 
very  comfortably  handled  through  the  transverse  incision.  But  if  it 
fills  the  loin  the  T-shaped  incision  il  preferable.  The  vertical  incision 
along  the  outer  border  of  the  rectuc  may  be  made  three  or  four  inches  in 
length  (Cabot  prefers  to  divide  the  rectus  and  make  his  vertical  branch 
in  the  median  line,  thereby  sparing  the  nerves).  Through  this  incision 
the  peritoneum  may  be  boldly  entered  and  the  renal  pedicle  tied  off 
before  the  kidney  is  disturbed  at  all.  Then  the  veins  over  the  surface 
of  the  kidney,  most  of  which  anastomose  with  some  peritoneal  vessels 
about  the  lower  pole,  are  taken  care  of.  Then  the  tumor  is  removed  with 
due  respect  for  the  position  of  the  vena  cava. 

As  an  aid  to  the  removal  of  the  kidney,  we  may  note  the  resection 
of  the  outer  portion  of  the  last  rib.  This  is  done  just  as  in  the  operation 
for  empyema,  great  care,  however,  being  taken  to  spare  the  pleura.  I 
have  never  resected  the  rib,  and  Albarran  states  that,  in  several  hun- 
dred kidney  operations,  he  has  only  had  to  do  this  four  or  five  times. 

Accidents  During  the  Operation. — The  peritoneum  may  he  torn 
during  the  operation.  Thir.  accident  is  unimportant,  even  though  the 
kidney  be  septic.  The  peritoneal  cavity  is  walled  ofi"  with  pads  and 
the  operation  continued  in  the  usual  manner.  At  its  termination  the 
peritoneum  is  sutured. 

Incision  of  the  pleura  is  attended  to  in  the  manner  already  described 
(p.  686). 


NEPHRECTOMY  FOE  NEOPLASM  699 

Tearing  of  the  hidncy  itself,  or  of  its  pelvis,  in  an  unfortimate  com- 
plication, since  it  may  rendei"  septic  an  operation  that  would  otherwise 
be  clean, 

//  the  ligature  slips  from  the  pedicle  the  immediate  hemorrhage  is 
terrifying ;  but  there  is  no  grave  danger  so  long  as  the  surgeon  does  not 
become  panic-stricken.  He  should  plunge  his  hand  into  the  wound  and 
grope  for  the  rush  of  blood  as  it  issues  from  the  vessels.  Gentle  pressure 
proximal  to  this  point  promptly  controls  the  bleeding.  Clots  are  then 
mopped  out  and  the  wound  widely  retracted  so  that  the  bleeding  points 
can  be  seen  and  clamped.  Under  no  circumstances  should  clamps  be 
used  wildly  and  blindly  in  the  depths  of  the  wound. 

Tearing  of  the  vena  cava  is  an  extremely  grave  accident. 

Postoperative  Complications — Hemorrhage  may  be  controlled  by 
packing. 

Insufficiency  of  the  opposite  Tciclney  should  be  foreseen  and  pre- 
vented by  Murphy  drip  and  colon  irrigations. 

One  should  operate  on  the  third  day  of  anuria,  even  without  symp- 
toms, or  on  the  first  appearance  of  twitching  during  sleep,  contortions 
of  the  pupil,  or  headache. 

Urinary  fistulae  sometimes  follow  the  operation,  the  urine  being  dis- 
charged up  the  ureter  from  the  bladder.  Such  discharges  ultimately 
cease.  Purulent  fistulae  require  secondary  operations.  These  should 
be  performed,  if  possible,  behind  the  scar  of  the  first  operation,  in  order 
to  spare  the  peritoneum. 


CHAPTEK    LXXII 
OPERATIONS  UPON  THE  URETERS 

INCISION  OF  THE  PARIETES 

The  abdominal  portion  of  the  ureter  may  be  readied  extraperi- 
toneally,  either  through  the  usual  oblique  lumbo-abdominal  incision  ex- 
tended well  forward,  or  through  a  vertical  incision  at  the  outer  border 
of  the  rectus. 

The  lower  pelvic  portion  of  the  ureter  can  be  reached  by  median 
section.^  The  incision  usually  employed  lies  to  the  outer  side  of  the 
rectus  below  the  umbilicus.  I  much  prefer  Gibson's  -  incision :  a  demi- 
Pfannenstiel,  extending  in  a  curve  from  the  anterior  superior  spine  to 
and  across  the  median  line  just  above  the  pubes.  The  internal  oblique 
and  transversalis  muscles  are  divided  vertically  at  the  outer  edge  of  the 
rectus. 

The  patient  is  put  in  the  Trendelenburg  position  either  before  or 
immediately  after  the  incision  of  the  parietes. 

When  the  peritoneum  is  reached  this  is  drawn  toward  the  median 
line  and  carefully  dissected  free  from  the  lateral  pelvic  wall,  carrying 
the  ureter  with  it.  This  duct  is  identified  where  it  crosses  the  brim  of 
the  pelvis  at  the  iliac  bifurcation  and  followed  down  to  its  insertion  into 
the  bladder. 

URETEROTOMY  FOR  STONE 

In  the  female,  large  stones  caught  just  external  to  the  bladder  may 
be  reached  by  incision  in  the  vaginal  vault;  but  if  the  stone  is  at  all 
movable  it  is  fixed  in  this  position  with  great  difficulty,  and  when  the 
incision  in  the  vaginal  vault  has  been  made  the  stone  will  be  found  to 
have  slipped  out  of  reach  up  the  ureter.  For  small  stones,  therefore, 
even  in  the  female,  the  abdominal  route  is  preferable. 

Stones  caught  in  the  intravesical  portion  of  the  ureter  may  be  ex- 
tracted either  by  intravesical  operation  (p.  760)  or  by  suprapubic  cys- 
totomy (p.  719). 

^  Judd  (Ann.  Surg.,  1914,  ]ix,  393),  Squier  and  Warren  (Trans.  Am.  Assn.  G.V. 
Surg.,  1915)   often  employ  the  median  incision. 

*  Trans.  Am,  Gen.  TJrin.  Assn.,  1909,  vol.  iv. 

700 


PLASTIC  OPERATIONS  701 

Small  stones  should  be  encouraged  to  pass  by  injection  of  the  ureter 
(p.  398). 

With  these  exceptions  the  stone  must  be  reached  through  one  of 
the  abdominal  incisions  described  above.  If  there  is  any  possibility 
that  the  stone  i  movable  one,  a  radiograph  should  be  taken  imme- 
diately before  operation. 

Most  stones  for  which  operation  is  required  are  found  fixed  in  the 
lower  ureter  at  thu  level  of  the  spine  of  the  ischium,  or  bej'ond  this. 
If  the  stone  is  movable,  it  may  often  be  readily  milked  up  into  some 
more  accessible  portion  of  the  ureter  in  which  a  vertical  incision  is 
made,  after  the  ureter  above  this  point  has  been  gently  compressed  by 
an  assistant'?  fingers  or  a  protective  clamp.  Before  closing  the  ureter 
a  large-sized  probe  should  be  passed  down  into  the  bladder  to  dilate 
any  stricture  that  may  be  present. 

If  the  stone  cannot  be  moved  by  external  pressure  one  may  attempt 
to  dislodge  it  by  a  Mayo  gall-stone  scoop  introduced  through  an  inci- 
sion in  the  ureter  higher  up.  Even  this  may  fail,  however,  and  in  that 
event  it  is  necessary  to  incise  the  ureter  over  the  stone.  At  this  point 
the  ureter  is  likely  to  be  relatively  inflamed  and  there  are  theoretical 
objections  to  incising  it ;  but  I  have  done  this  several  times  and  seen  no 
harm  result.  After  incision  of  the  ureter  one  should  never  forget  to 
pass  the  probe  into  the  bladder.  The  incision  ic  then  caught  together 
by  several  intestinal  sutures  of  catgait,  a  cigarette  drain  left  in  the 
wound,  and  the  parietes  closed  around  this. 

The  drain  may  be  removed  at  the  end  of  forty-eight  hours.  Rubber 
tubing  should  never  be  employed  for  drainage  in  the  pelvis  lest  it 
result  in  secondary  hemorrhage  from  pressure  on  the  iliac  arteries  as 
described  by  Moschowitz.^ 

Cabot  ^  mentions  three  cases  treated  without  drainage.  I  have 
omitted  drainage  in  several  of  my  own  cases,  but  one  had  a  rather 
stormy  convalescence  as  the  result  of  mild  subperitoneal  infection. 

PLASTIC  OPERATIONS 

Plastic  operations  are  employed  whenever  possible  for  the  reestab- 
lishment  of  the  lumen  of  an  obstructed  ureter.  Previous  to  operation 
the  functional  capacity  of  the  kidney  is  studied  and  if  this  is  worth  pre- 
serving the  ureteral  obstruction  is  defined  by  pyelography. 

It  will  be  found  that  in  the  great  majority  of  cases  the  liberation 
of  adhesions,  and  the  straightening  out  of  kinks  in  the  ureter,  nephro- 
pexy or  incision  of  strictures  with  postoperative  drainage  by  ureter 
catheter  for  at  least  ten  days,  will  relieve  such  obstructions  as  have 

*  Annals  of  Surgery,  1908,  xlviii,  872. 

-Boston  Med.  ^  Surg.  Jour.,  1910,  clxiii,  789. 


702 


OPERATIONS  UPON  THE  URETERS 


not  totally  destroyed  the  kidney. 
Exceptionally,  however,  a  real  plas- 
tic operation  is  required  to  relieve 
obstructions  at  the  junction  of  the 
ureter  and  kidney  pelvis.  Eliot  ^ 
has  collected,  classified  and  enumer- 
ated 111  cases  according  to  the  fol- 
lowing plan: 

1.  Division  of  Spur. — (11 
cases.)  If  the  ureter  is  adherent 
for  some  distance  along  the  wall  of 
the  pelvis  the  obstruction  may  be 
sometimes  relieved  by  incising  the 
spur  and  suture  of  the  correspond- 
ing edges  of  the  incision  to  each 
other  so  as  to  leave  an  open  orifice. 

2.  Ureter opyeloneostomy (18 

cases.)  The  ureter  is  divided  and 
re-implanted  in  the.  lowest  portion 
of  the  kidney  pelvis.  Before  im- 
plantation the  tip  of  the  ureter 
should  be  split  for  half  a  centimeter 
on  each  side  and  the  flaps  thus  produced  should  be  affixed  to  the  inner 
surface  of  the  kidney  pelvis  by  a  single  suture  each. 


Fig.  154. — Ureteroplasty  or  Pyelo- 
URETEROTRESis  (after  Morris).  The 
stricture  is  incised  longitudinally  and 
two  sutures  are  inserted. 


Fig.  155. — Ureteroplasty  or  Pyelo- 
URETEROTRESis  (after  Morris).  The 
sutures  are  drawn  so  as  to  make  the 
incision  transverse. 


Fig.  156. — Ureteroplasty  or  Pyelo- 
tRETEROTRESis  (after  Morris).  The 
result. 


3.  Ureteroplasty. — (27  cases.)     Stricture  at  the  ureteral  orifice  is 
incised  longitudinally  and  sutured  transversely. 
Wour.  d'Vrol.,  February  15,  1913,  ill,  2. 


PLASTIC  OPERATIONS 


703 


4.  Lateral  Anastomosis. —  (20  cases.)     The  ureteral  canal  is  opened 
longitudinally  at  a  point  opposite  the  lowest  portion  of  the  kidney  pelvis 
and  this  incision  sutured  to  a 
corresponding  one  in  the  pel- 
vis. 

5.  Pyeloplication.  —   (10 

cases.)  The  bulging  pelvis  is 
crumpled  permanently  by  a 
series  of  nonpenetrating  in- 
and-out  sutures. 

6.  Resection  of  the  Pelvis. 
— (10  cases.)  The  bulging  pel- 
vis is  cut  away  and  resected. 

Eliot  mentions  four  cases 
in  which  the  dilated  pelvis  of 
a  misplaced  kidney  was  anas- 
tomosed directly  with  the 
bladder  and  also  ten  atypical 
operations. 

General  Principles. — The 
rules    will    be    of 


Fig.  157. — End-in- 
END  Anastomo- 
sis.   (Poggi.) 


following 


Fig.  158. — O  b  l  i  q  u  e 
End-to-end  Anas- 
tomosis.    (Bovee.) 


service : 
1.  The  drainage  obtained  by  a  plastic  operation  is  likely  to  be  much 
less  satisfactory  in  the  performance  than  in  the  description.     Therefore 


A 
Fig.  159. 


B  C 

-Lateral    Anastomosis. 
(Van    Hook.) 


Fig.  160. — Lateral  Anastomosis.  (Bache  Emmet.) 


every  effort  should  be  made  to  relieve  ureteral  obstniction  by  other 
means  without  plastic  operation. 


704  OPERATIONS  UPON  THE  URETERS 

2.  If  tlie  sutures  are  to  hold  there  must  be  literally  absolutely  no 
tension  between  the  ureter  and  the  kidney  pelvis. 

3.  All  penetrating  sutures  must  be  of  plain  catgut ;  nonpenetrating 
sutures  may  be  of  silk  or  linen. 

4.  In  order  to  encourage  firm  union  the  kidney  should  be  drained 
through  the  loin  for  at  least  a  week  and  during  this  time  the  points  of 
union  should  be  kept  open  by  means  of  a  ureter  catheter  or  a  small 
catheter  introduced  through  the  kidney  into  the  orifice  of  the  ureter. 


REPAIR  OF  URETERAL  WOUNDS 

Direct  end-to-end  anastomosis  predisposes  to  stricture.  In  order  to 
avoid  this  the  three  following  methods  have  been  devised  (but  unfortu- 
nately in  most  instances  so  much  of  the  ureter  is  destroyed  that  none 
of  them  can  be  employed). 

1.  End-in-end  anastomosis. 

2.  Oblique  end-to-end  anastomosis. 

3.  Lateral  anastomosis  (end-in-side). 

End-in-end  Anastomosis — This  operation  was  first  suggested  by 
Poggi,  and  has  been  modified  by  Mayo  Robson  ^  and  Gubaroff.^  The 
upper  end  of  the  ureter  is  cut  obliquely  (to  prevent  stricture)  and  the 
lower  end  dilated  (Poggi)  (Fig.  157)  or  incised  longitudinally  (Rob- 
son).  The  upper  end  is  then  drawn  into  the  lower  by  a  single  suture, 
as  in  Van  Hook's  operation,  the  longitudinal  incision  sutured,  and  the 
union  streng-thened  by  a  circle  of  fine  silk  Lembert  sutures  around  the 
external  line  of  union. 

Oblique  End-to-end  Anastomosis  (Wesley  Bovee). — Both  ends  are 
cut  obliquely,  dilated,^  and  sutured  with  rectangular  and  simple  inter- 
rupted sutures,  re-enforced  by  a  few  Lembert  sutures  (Fig.  158). 

It  is  convenient  in  this,  as  in  most  of  the  other  plastic  operations 
upon  the  ureter,  to  suture  the  tube  after  the  introduction  (from  the  blad- 
der) of  a  urethral  catheter,  or,  as  Howard  Kelly  ^  has  suggested,  a  guide 
introduced  through  a  longitudinal  incision  in  the  wall  of  the  duct. 

Lateral  Anastomosis  (Van  Hook). — 

a.  Ligate  the  lower  portion  of  the  tube  i  or  ^  inch  from  the  free  end. 
Make  with  fine  sharp-pointed  scissors  a  longitudinal  incision  twice  as  long  as 
the  diameter  of  the  ureter  in  the  wall  of  the  lower  end,  ^  inch  below  the 
ligature. 

^Internat.  Med.  Ann.,  1896,  p.  602. 

'Centralll.   f.    Chir.,    1901. 

•  The  ureter  can  be  dilated  with  ease  to  twice  its  normal  size. 

*Jour.  of  the  Am.  Med.  Assn.,  1900,  xxxv,  860. 


REPAIR  OF  URETERAL  WOUNDS  705 

6.  Make  an  incision  with  the  scissors  in  the  upper  portion  of  the  ureter, 
beginning  at  the  open  end  of  the  duct  and  carrying  it  up  i  inch.  This  inci- 
sion insures  the  patency  of  the  tube  (Fig.  159,  A). 

c.  Pass  two  very  small  cambric  needles  armed  with  one  thread  of  ster- 
ilized catgut  through  the  wall  of  the  upper  end  of  the  ureter  J  inch  from  the 
extremity,  from  within  outward,  the  needles  being  from  -^^  to  g  inch  apart, 
and  equidistant  from  the  end  of  the  duct.  It  will  be  seen  that  the  loop  of 
catgut  between  the  needles  firmly  grasps  the  end  of  the  ureter. 

d.  These  needles  are  now  carried  through  the  slit  in  the  side  of  the  lower 
end  of  the  ureter  into  and  down  the  tube  for  i  inch,  where  they  are  pushed 
through  the  wall  of  the  dnct  side  by  side   (Fig.  159,  B). 

e.  It  will  now  be  seen  that  the  traction  upon  this  catgut  loop  passing' 
through  the  wall  of  the  ureter  Avill  draw  the  upper  fragment  of  the  duet  into 
the  lower  portion.  This  done,  the  ends  of  the  loop  are  tied  together  securely, 
and,  as  the  catgut  will  be  absorbed  in  a  few  daj^s,  calculi  do  not  form  to 
obstruct  the  passage  of  urine  (Fig.  159,  C). 

f.  The  ureter  is  now  enveloped  carefully  with  peritoneum.  This  may  be 
done  by  lifting  the  duct  gently  into  the  cavity  of  the  peritoneum,  drawing  down 
the  serous  membrane  carefully  behind  the  ureter,  and  after  pulling  the 
peritoneum  around  it,  stitching  it  in  a  position  to  permanently  inclose  and 
protect  the  tube.^ 

Bache  Emmet  employs  three  sutures  to  drag  the  upper  segment  into 
the  lower  one.  This  for  the  purpose  of  puckering  the  upper  segment,  if 
it  is  considerably  dilated  (Fig.  160). 

We  may  disregard  the  discussion  of  the  relative  methods  of  the  three 
procedures,  but  the  following  observations  seem  apposite: 

1.  Invagination,  whether  end-in-end  or  end-in-side,  may  be  per- 
formed more  easily  and  rapidly  than  Bovee's  operation. 

2.  End-in-side  anastomosis  wastes  more  of  the  lengih  of  the  duct 
than  either  of  the  other  two.  Bovee  claims  that  his  operation  may  be 
performed  even  though  as  much  as  3  inches  of  the  duct  have  been  cut 
away.^  He  has  also  suggested  that  in  case  of  need  the  kidney  may  be 
loosened  and  stitched  low  in  the  loin. 

3.  Whatever  method  is  employed  it  is  customary  to  use  catgut  for 
all  sutures  that  enter  the  lumen  of  the  duct,  and  silk  for  the  others ;  this 
in  order  to  avoid  calculous  incrustation. 

4.  When  the  lower  end  of  the  ureter  is  divided  or  strictured,  cysto- 
ureterotresis  is  the  operation  of  choice.  When  this  is  impracticable, 
the  choice  lies  between,  cutaneous  fistulization  and  nephrectomy,  with 
a  preference  for  the  latter,  if  the  opposite  kidney  is  able  to  support  life. 

Cysto-ureterotresis — Cysto-ureterotresis  (ureterocystoneostomy)  is 
the  implantation  of  the  ureter  into  an  incision  in  the  bladder  wall.  It 
has  been  usually  employed  for  the  relief  of  ureterovaginal  fistula,  and 
after  operative  resection  of  the  lower  ureter. 

^  Van  Hook  is  liere  speaking  of  an  intraperitoneal  operation,  which  ureteral 
anastomosis  almost  always  is. 

^  Jour,  of  the  Am.  Med.  Assn.,  1901,  xxxvii,  254. 


706  OPERATIONS  UPON  THE  URETERS 

Poggi,  in  1887,  made  the  first  experiments  in  reference  to  this  op- 
eration.    Novaro  and  Bazy  were  the  first  to  perform  it. 

Three  routes  have  been  chosen — viz.,  vaginal,  sacral,  and  abdominal. 
The  vaginal  and  sacral  routes  have  nothing  to  recommend  them. 

Almost  everj  surgeon  who  has  performed  the  abdominal  operation 
has  devised  his  own  technic.  The  various  methods  have  been  enumer- 
ated by  Boari  ^  and  Morris.-  To  avoid  confusion,  it  is  best  to  describe 
only  a  type  operation.  The  peculiarities  of  each  case  will  suggest  the 
necessary  modifications. 

Whether  the  ureter  is  to  be  attached  intraperitoneally  or  extraperi- 
toneally  is  decided  by  the  features  of  the  case.  It  is  safer  to  operate 
extraperitoneall,y  through  the  lumbo-ingaiinal  incision  when  possible, 
elevating  the  peritoneum  nntil  the  bladder  (distended  with  boric  acid 
solution)  is  entirely  exposed,  freeing  the  ureter  from  the  peritoneum 
and  drawing  it  down. 

The  bladder  is  then  emptied  by  catheter  and  incised  on  the  point  of 
a  sound  at  the  most  convenient  point.  The  ureteral  orifice  is  then  split 
to  prevent  stenosis,  and  attached  to  the  bladder  by  means  of  a  catgut 
traction  suture  (as  in  the  Xan  Hook  anastomosis).  It  is  convenient  at 
this  juncture  to  introduce  a  ureteral  catheter  and  upon  it  to  suture  the 
outer  layers  of  ureter  and  bladder.  When  the  operation  is  performed 
within  the  peritoneum  the  line  of  union  should  be  protected  by  a  peri- 
toneal or  an  omental  fold. 

After  operation  it  is  customary  to  leave  the  ureteral  catheter  in  place 
for  a  week. 

The  success  of  the  operation  depends  upon  the  absence  of  any  tension 
whatever  hetiveen  the  ureter  and  the  bladder.  But  even  so,  renal  in- 
fection results  in  the  great  majority  of  cases.  This  may  subside  or 
may  require  nephrectomy. 

In  several  instances  the  ureter  has  seemed  too  short.  An  inch  or 
more  may  be  gained  by  loosening  the  pubic  attachments  of  the  bladder 
(Witzel,  Kelly,  Penrose)  and  suturing  its  fundus  to  the  lateral  pelvic 
wall. 


OPEEATIONS   TO  DIVERT  THE   URINARY  STREAM 

Nephrostomy — The  operation  has  been  described  on  page  691.  If 
the  nephrostomy  is  to  be  permanent  the  ureter  must  be  ligated  with  silk. 
Cups  have  been  devised  by  Watson  of  Boston,  Loux  of  Philadelphia,  and 
others  to  etitch  the  urine  from  a  loin  fistula. 

Ureterostomy. — Implantation  of  the  ureter  into  the  loin  may  be 

^Guyon's  Annalcs,  1899,  xvii,  1059,  1141. 
'  Op.  fit.,  ii,  563. 


OPERATIONS  TO  DIVERT  THE  URINARY  STREAM  707 

done  much  more  readily  than  nephrostomy,  for  it  is  no  easy  matter  to 
open  the  normal  kidney  pelvis  and  drain  the  organ  in  such  a  way  that 
it  will  remain  fistulous;  whereas  through  a  rather  high  Pfannenstiel 
incision,  with  division  of  the  deeper  muscles  at  the  outer  border  of  the 
rectus  on  each  side,  each  ureter  may  be  picked  up  where  it  crosses  the 
brim  of  the  pelvis  at  the  bifurcation  of  the  iliac  vessels,  freed  well  down 
into  the  pelvis  and  up  into  the  loin,  and  brought  out  at  a  convenient 
spot  in  the  side  without  difficulty.  The  best  point  for  implantation 
may  be  found  at  the  center  of  an  imaginary  circle  made  by  placing  a 
goblet  on  the  side  at  a  point  where  its  edge  will  neither  touch  the  ribs 
nor  the  crest  of  the  ilium.  The  skin  and  muscles  are  punctured  at  this 
point  and  a  long  pair  of  forceps  driven  through  into  the  subperitoneal 
space.  With  this  the  divided  end  of  the  ureter  is  caught  and  brought 
out  of  the  side.  The  ureter  must  be  freed  sufficiently  to  permit  at 
least  an  inch  of  it  to  hang  free  outside  of  the  skin  without  tension  and 
without  kinking  within.  The  ureter  is  caught  in  place  by  two  light 
catgut  sutures,  and  a  ureter  catheter  introduced  to  the  kidney  pelvis 
in  order  to  minimize  the  retention  and  the  acute  renal  infection  which 
inevitably  follow  ureteral  transplantation. 

Both  ureterostomy  and  nephrostomy  are  filthy  procedures  liable  to 
stoppage  of  the  fistulous  tract  and  consequent  acute  renal  infection  or 
retention  with  fatal  results.  The  most  satisfactory  cases  in  this  regard 
have  been  those  of  pyonephrosis  with  kidney  pelves  so  distended  that 
they  could  be  readily  and  largely  anastomosed  to  the  loin. 

Ureteral  Anastomosis  with  the  Intestine. — Some  of  the  innumer- 
able methods  devised  for  implanting  ureters  into  the  intestines  are  de- 
scribed: and  discussed  by  Zesas.^  The  following  rules  may  be  laid 
down; 

The' implantation  must  be  made  entirely  without  tension. 

2.  The  exclusion  of  a  loop  of  intestine  to  form  an  artificial  bladder 
has  proven  almost  universally  unsuccessful. 

3.  The  ureter  must  be  implanted  obliquely. 

4.  The  cause  of  failure  is  either  leakage  at  the  point  of  union  or 
ascending  infection  of  the  kidney.  This  almost  inevitably  occurs  just 
as  it  does  after  ureteral  implantation  into  the  skin,  but  with  this  dif- 
ference, that  it  is  impossible  to  provide  adequate  drainage  with  the 
ureter  mouth  lost  in  the  bowel.  The  vast  majority  of  operations  have 
proven  fatal.  Statistics  collected  from  the  few  successful  cases  bear 
no  relation  to  the  actual  facts.  Coffey  ^  states  that  Mayo  has  success- 
fully implanted  both  ureters  of  twelve  patients  by  the  following 
method :  ^ 

^Veiotsche  Zeitschr.  f.  Chir.,  1909,  ci,  3. 
"Jour.  A.  M.  A.,  1915,  Ixv,  1246. 
'Ibid.,  1911,  Ivi,  397. 


708 


OPERATIONS  UPON  THE  URETERS 


First,  the  duet  is  located  and  ligated  with  linen  or  silk.  It  is  then  cut 
in  two  above  the  ligature  and  the  edges  caught  and  held  with  mosquito  forceps 
while  one  wall  of  the  duet  is  split  down  with  a  pair  of  scissors.  A  linen  suture 
is  now  passed  through  the  split  end  of  the  duet  so  as  to  include  about  one-half 
of  it,  and  tied.  The  linen  thread  is  then  thrown  around  the  other  half  and 
tied. '  The  loose  ends  are  then  threaded  into  two  needles.  By  this  method  the 
full  strength  of  the  duct  is  retained  for  traction,  while  the  opening  is  main- 
tained by  the  split.  The  end  of  the  duct  is  now  wrapped  with  gauze  while 
the  intestine  is  prepared  for  its  reception,  which  is  done  as  follows : 

The  part  of  the  intestine  desired  is  picked  up  and  an  incision  made  down 
through  the  peritoneal  and  muscular  coats,  including  submucous  tissue  until 
the  mucous  membrane  pouts  out  through  the  incision  (Fig.  161).  This  incision 
should  be  about  one  inch  long  or  more.     Second,  five  or  six  sutures  are  passed 


Fig.  161. — Ubetero-intestinal  Anastomosis.      (Coffey.) 


which  pick  up  the  peritoneal  and  muscular  coats  on  each  side  of  the  incision. 
The  suture  at  the  upper  end  of  the  incision  is  tied  as  a  control  suture.  The 
intermediate  intestinal  sutures  are  lifted  up  on  the  flat  handle  of  an  instru- 
ment as  they  cross  the  incision.  Now  the  intestine  is  brought  down  close  to 
the  end  of  the  split  duct  and  the  two  needles  carrying  the  threads  (traction 
sutures)  on  the  end  of  the  duct  are  passed  beneath  the  four  or  five  intestinal 
sutures  and  through  the  stab  wound  in  the  mucous  membrane  into  the  intestinal 
lumen  and  out  through  the  intestinal  wall  three-quarters  of  an  inch  farther 
along  the  intestine,  and  one-eighth  to  one-quarter  inch  apart.  By  making 
tension  on  these  threads  and  at  the  same  time  pushing  the  intestine  toward  the 
duct,  the  duct  is  drawn  beneath  the  intestinal  sutures  through  the  stab  wound 
into  the  intestinal  lumen,  when  the  two  ends  of  the  threads  on  the  duet  are 
tied  on  the  outside,  thus  anchoi'ing  the  end  of  the  duct  on  the  inside  of  the 
mtestine  at  this  point  (Fig.  161).  The  intestinal  sutures  are  then  tied.  After 
this  operation  the  duet  lies  just  beneath  the  mucous  membrane,  which  has  been 
loosened  for  approximately  three-quartei's  of  an  inch  of  its  course,  so  that  it 
slides  easily  in  its  new  channel.  It  is  therefore  necessaiy  to  tack  the  ureter 
to  the  peritoneum  of  the  intestine  near  its  point  of  entrance  by  two  or  three 
fine  linen  or  silk  sutures.  Care  should  be  used  to  take  only  the  outer  coat  of 
the  ureter  in  the  bite  of  these  sutures. 


OPERATIONS  TO  DIVERT  THE  URINARY  STREAM  709 

Maydl's  Operation — In  1894  MaydP  reported  his  first  cases  of 
ureterotrigonal  anastomosis.  This  operation  consists  of  the  implanta- 
tion into  the  colon,  not  of  the  ureter  itself,  but  of  the  bladder  wall  sur- 
rounding the  mouth  of  the  ureter.  The  operation  has  usually  been  em- 
ployed for  exstrophy  of  the  bladder,  and  is  performed  as  follows:  A 
ureteral  catheter  is  introduced  into  each  ureter  and  an  elliptical  section 
surrounding  the  mouths  of  both  ureters  is  then  cut  from  the  bladder 
wall,  great  care  being  taken  not  to  injure  the  ureters.  Xext,  the  peri- 
toneal cavity  is  opened.  A  convenient  loop  of  the  sigmoid  flexure  or 
the  rectum  is  selected  and  brought  out  of  the  abdominal  wound.  The 
ureters,  with  their  attached  portion  of  trigone,  are  then  freed,  a  longi- 
tudinal incision  is  made  in  the  wall  of  the  gut,  with  the  necessary 
precautions,  and  into  this  the  section  of  trigone  is  sutured.  The  re- 
mainder of  the  bladder  is  now  stripped  of  its  mucous  membrane  and 
the  abdominal  wound  closed  as  tightly  as  possible,  with  splitting  and 
transposition  of  the  recti,  if  necessary.  As  a  final  precaution  the 
sphincter  ani  is  stretched  and  a  tube  inserted  and  left  in  for  several 
days  to  establish  drainage  and  to  minimize  the  danger  of  leakage  and 
renal  retention. 

The  immediate  mortality  from  .shock  and  infection  is  at  least  25 
per  cent.  Yet  the  operation  continues  to  enjoy  a  popularity  founded 
upon  the  hope  that  springs  eternal  in  the  ambitious  surgeon's  breast. 

Peters 's  Operation.^ — This  modification  of  Maydl's  procedure  con- 
sists in  dissecting  out  each  ureter  separately  with  its  surrounding  bit 
of  trigone,  and  implanting  each  in  a  separate  hole  punctured  in  the  an- 
terior rectal  wall  immediately  behind  the  wound  made  by  freeing  the 
ureters,  the  whole  operation  being  extraperitoneal.  The  ureter  ends 
hang  free  in  the  rectum.  The  ureter  catheters  are  immediately  with- 
drawn and  the  sphincter  stretched  to  prevent  back  pressure.  This  is 
the  simplest  and  safest  of  all  the  operations  devised  for  the  cure  of 
exstrophy.  It  should  be  performed  on  patients  between  the  ages  of  5 
and  15. 

^Wien.  med.  Wochenschr.,  1894,  xliv,  1113,  1169,  1209,  1256,  1297.  Ibid.,  1896, 
xlvi,  1241,  1333,  1373.  Ibid.,  1899,  xliv,  249,  304,  3G0.  Cf.  also  Frank,  Deutsche 
Zeit.schr.  f.  Chir.,  1912,  exiii,  427;  Oppel,  Vrol.  and  Cutan.  Beview,  1913,  I,  1;  and 
Mayo,  Ann.  Surg.,  1913,  Iviii,  133. 

*Brit.  Med.  Jour.,  1901,  June  22. 


CHAPTER   LXXIII 
ANATOMY   OF  THE  BLADDER— SUPRAPUBIC   OPERATIONS 

ANATOMY 

The  bladder  is  a  muscular  sac  lying,  in  the  male,  between  the  rec- 
tum and  the  pnbes  when  empty,  and  distending,  when  full,  into  an  oval 
bag  occupying  more  or  less  of  the  hypogastrium  (Fig.  IT).  Its  posi- 
tion is  fixed  below  by  the  urethra,  by  the  pelvic  fascia  (as  puboprostatic 
and  inferior  vesical  ligaments),  and  by  the  rectovesical  fascia,  which 
binds  the  prostate  and  the  neck  of  the  bladder  to  the  rectum.  The 
muscular  tissue  of  the  organ  is  covered  on  the  outside  by  peritoneum, 
on  the  inside  by  mucous  membrane. 

Above  and  on  the  sides  the  peritoneum  covers  the  bladder.  When 
the  bladder  is  empty  it  lies  contracted  behind  the  pubes ;  the  peritoneum 
leaves  the  abdominal  walls  at  the  symphysis  and  passes  at  once  to  the 
bladder,  over  which  it  is  spread,  and  thence  reflected  upon  the  rectum 
from  the  base  of  the  bladder,  so  that  when  the  latter  is  absolutely  or 
even  partially  empty  no  trocar  or  aspirating  needle  may  reach  it  from 
the  anterior  abdominal  wall  without  traversing  the  peritoneal  cavity. 

Very  diiferent,  however,  is  the  condition  of  the  viscus  when  dis- 
tended. Then,  as  its  cavity  fills  up,  the  peritoneum  is  carried  with  it. 
In  this  way  the  distended  bladder  carries  up  the  peritoneum  in  front, 
so  that  in  extreme  retention  a  distance  of  2  to  5  cm.  above  the  symphy- 
sis becomes  bare  of  peritoneum.  Hence  the  election  of  the  region 
immediately  above  the  pubes  for  aspiration  of  the  bladder. 

The  relation  of  the  peritoneum  to  the  bladder  also  varies  behind. 
When  the  viscus  is  distended  the  peritoneum  barely  reaches  the  blind 
ends  of  the  seminal  vesicles ;  when  empty  it  descends  between  them 
almost  to  the  prostate. 

The  shape  of  the  bladder  varies  with  age.  The  bladder  of  an  infant 
is  ovoidal  in  shape,  with  its  long  axis  running  downward  and  a  little 
forward,  and  its  apex  at  the  urethral  orifice.  It  lies,  when  full,  almost 
entirely  out  of  the  pelvis.  As  age  advances  the  bladder  sinks  into  the 
pelvis,  assumes  an  almost  spherical  shape  when  filled  and  possesses  a 
flattened  floor  in  the  region  of  the  trigone. 

The  muscle  of  the  bladder  is  composed  of  three  coats — external, 
middle,  and  internal.     The  external  or  longitudinal  coat  consists  of 

710 


ANATOMY  711 

numerous  fibers  running  from  the  prostate  up  over  the  fundus,  where 
thej  are  met  bv  a  similar  set  of  fibers  from  the  anterior  surface.  At 
the  place  of  meeting  there  is  a  swirl  or  "cowlick"  of  muscle  fibers.  Over 
the  sides  of  the  organ  the  longitudinal  layer  is  thin  and  unimportant. 
Its  fibers  are  closely  connected  with  the  prostate  and  the  deep  layer  of 
the  rectovesical  fascia,  and  intermingle  with  the  deeper  layers  of  the 
bladder  muscle.  The  middle  layer  forms  the  bulk  of  the  vesical  muscle. 
Its  fibers  are  densely  interlaced  and  have  a  generally  circular  character. 
The  internal  layer  of  muscle  consists  of  a  few  scattering  bundles  of 
longitudinal  fibers,  so  irregular  and  inconspicuous  that  some  anatomists 
deny  their  existence. 

The  trigone  of  the  bladder  is  part  of  the  urethra  (p.  37). 

The  mucous  memhrane  of  the  bladder  is  of  a  pale  salmon  color,  re- 
markably insensitive  in  health,  except  at  the  ureter  orifices,  covered 
by  a  stratified  pavement  epithelium,  and  lies  in  folds  when  the  bladder 
is  contracted,  except  over  the  trigone,  where  it  is  always  smooth.  The 
glands  are  few  and  occur  almost  exclusively  on  the  trigone.  They  are 
exceedingly  small.  A  little  lymphoid  tissue  is  usually  found  irregu- 
larly distributed  in  the  mucosa.  The  coats  of  the  bladder  are  united 
by  connective  tissue,  which  is  everywhere  loose,  except  at  the  trigone. 

The  bladder  is  arbitrarily  described  as  being  composed  of  a  vault, 
two  lateral  walls,  a  fundus  (the  pouch  behind  and  above  the  trigone), 
and  a  trigone.  The  urethral  orifice  is  often  spoken  of  as  the  bladder 
neck.  The  ureters  pierce  the  floor  of  the  bladder  obliquely  and  open 
at  the  lateral  angles  of  the  trigone. 

The  arteries  of  the  bladder  are  the  superior,  middle,  and  inferior 
vesical.  They  anastomose  freely.  The  veins  are  numerous  and  lie  in 
three  planes — the  subserous,  the  intermuscular,  and  the  submucous. 
They  anastomose  freely  with  one  another  and  with  the  prostatic  plexus, 
and  the  plexus  of  Santorini  above  the  neck  of  the  bladder.  They  empty 
into  the  hypogastric  veins.  The  lymphatics  of  the  bladder  wall  were 
overlooked  by  the  older  anatomists,  but  their  existence  has  been  repeat- 
edly verified  of  late  years.  They  run  chiefly  beneath  the  mucous 
membrane  and  empty  into  several  small  groups  of  glands  lying  about  the 
bladder  itself  and  thence  into  the  iliac  glands  along  the  internal  and 
common  iliac  vessels.  These  iliac  glands  are  commonly  infected  by  vesi- 
cal neoplasms.  The  lumbar  glands  are  less  frequently  involved,  the 
inguinal  glands  very  rarely  (Pasteau^)  The  nerves  are  derived  from 
the  third  and  fourth  sacral  by  way  of  the  hypogastric  plexus. 

The  fetal  bladder  is  connected  with  the  allantois  by  the  urachus,  and 
this  canal,  closing  at  the  time  of  birth,  persists  as  a  fibrous,  subperi- 
toneal cord  connecting  the  fundus  of  the  bladder  with  the  umlulicus. 

^ ' '  Etat  du  systenie  lyniphatique  dans  les  maladies  de  la  vessie  et  de  la  pros- 
tate," Paris,   1898,  p.   48. 


712  ANATOMY  OF  THE  BLADDER— SUPRAPUBIC  OPERATIONS 

This  canal  very  exceptionally  remains  patent  througliout  the  whole  or  a 
part  of  its  length. 

ANESTHESIA  FOR  BLADDER  OPERATIONS 

Local  anesthesia  is  gaining  in  favor  for  suprapubic  section.  Punc- 
ture and  aspiration  of  the  bladder  may  be  done  without  any  anesthesia 
at  all,  or  with  only  a  drop  of  cocain  in  the  skin.  Suprapubic  cystostomy 
may  be  done  under  the  familiar  infiltration  anesthesia ;  one  has  only 
to  remember  that  the  bladder  itself  is  sensitive  and  requires  infiltra- 
tion as  well  as  the  parietes. 

But  if  any  work  is  to  be  done  inside  the  bladder,  even  though  this 
amount  to  so  little  as  the  removal  of  a  stone^  this  viscus  should  be  filled, 
before  the  infiltration  of  the  parietes  is  begun,  with  2  ounces  (75  c.c.) 
of  1  per  cent  novocain  solution.  Injection  of  cocain  solution  into  the 
normal  bladder  would  probably  do  no  harm,  but  one  never  operates 
upon  a  normal  bladder  and  the  inflamed  mucosa  may  absorb  the  drug. 
After  this  injection  the  abdominal  wall  is  infiltrated  and  opened  layer 
by  layer  as  described  below.  When  the  bladder  is  reached  the  novocain 
solution  is  drawn  off  through  the  catheter  and  the  bladder  filled  with 
boric  acid  solution  to  the  point  of  distention.  It  is  then  incised  and  the 
stones  removed. 

I  have  not  been  successful  with  local  anesthesia  for  more  extensive 
operations  upon  the  bladder.  The  prostate  can  sometimes  be  removed 
under  local  anesthesia ;  the  best  way  to  obtain  this  is  to  inject  the  anes- 
thetic into  the  vesical  surface  of  the  prostate.  On  the  whole  I  prefer 
the  anesthesia  described  in  the  section  on  prostatectomy. 

SUPRAPUBIC  OPERATIONS  UPON  THE  BLADDER 

The  following  are  the  types  of  operations  performed  upon  the  blad- 
der by  the  suprapubic  route : 

Puncture  and  aspiration  of  the  bladder. 
Suprapubic  cystotomy  and  cystostomy. 
Suprapubic  lithotomy. 
Suprapubic  section  for  tumor. 

Removal  of  pedunculated  growths. 

Partial  cystectomy. 
Intraperitoneal  cystotomy. 

Ureteral  implantation. 

Complete  cystectomy. 
Excision  of  diverticulum. 
Suprapubic  prostatectomy. 


SUPRAPUBIC  OPERATIONS  713 


PUNCTURE  OF  THE  BLADDER 


In  pre-antiseptic  days  puncture  of  the  distended  bladder  gave  such 
bad  results  that  it  was  abandoned  in  favor  of  aspiration.  Puncture 
may,  however,  be  employed  with  safety  if  a  few  simple  precautions  are 
taken. 

Indications. — Puncture  of  the  bladder  is  called  for  whenever  con- 
tinuous drainage  is  required  which  cannot  be  obtained  by  urethral 
catheter. 

Special  Instruments  Required. — Trocar  and  cannula  of  such  size 
that  a  15  French  soft-rubber  catheter  will  pass  snugly  through  the 
cannula.  The  catheter  should  have  two  eyes  and  should  be  of  soft 
rubber. 

Technic. — The  hypogastrium  is  shaved  and  prepared  as  for  a  major 
operation.  Before  beginning  the  operation,  the  surgeon  assures  himself 
by  percussion  and  palpation  that  the  bladder  underlies  the  abdominal 
wall,  and  that  no  intestines  intervene.  The  skin  is  then  infiltrated 
with  0.5  per  cent  cocain  solution  in  the  median  line  for  a  distance  of 
2  cm.,  beginning  immediately  above  the  pubes.  The  infiltrated  skin 
is  incised  and  drawn  apart  by  two  artery  clamps.  The  subcutaneous 
tissue  and  the  fascia  of  the  linea  alba  are  then  infiltrated  and  incised. 
The  trocar  and  cannula  are  then  introduced  through  the  incision  and 
plunged  into  the  bladder,  the  trocar  withdrawn  and  the  soft-rubber 
catheter  immediately  introduced  through  the  cannula  into  the  bladder 
before  the  urine  has  flowed  out  and  the  cannula  withdrawn. 

The  catheter  should  project  at  least  3  cm.  into  the  cavity  of  the 
Madder. 

It  is  then  caught  to  the  skin  by  a  suture  and  a  rubber  tissue  drain 
introduced  alongside  it  down  to  the  bladder  wall. 

After-treatment. — The  drain  is  withdrawn  in  forty-eight  hours,  the 
wound  protected  by  antiseptic  dressings  until  it  heals,  the  bladder 
irrigated  through  the  catheter  every  day,  and  the  catheter  attached  to 
an  appropriate  receptacle  to  catch  the  urine.  The  patient  need  not 
be  confined  to  bed  after  operation.  The  catheter  is  changed  every 
5  days. 

Complications. — If  the  proper  technic  is  precisely  followed  punc- 
ture of  the  bladder  is  perfectly  safe,  but  carelessness  in  asepsis  or  in 
technic  is  severely  penalized  by  pelvic  cellulitis  due  to  infection  or 
peritonitis  due  to  puncture  of  the  peritoneum. 

Infection  of  the  peritoneum  will  be  avoided  if  the  bladder  is  really 
distended  up  under  the  belly  wall  when  the  puncture  is  made,  and  the 
trocar  is  driven  into  the  bladder  just  as  close  to  the  upper  border  of  the 
pubes  as  possible,  and  the  catheter  introduced  immediately,  before  the 
bladder  can  empty  itself. 


714   ANATOMY  OF  THE  BLADDER— SUPRAPUBIC  OPERATIONS 

ASPIRATION  OF   THE   BIiADDER 

The  hypogastrium  is  prepared  antiseptically  and  the  bladder  per- 
cussed as  for  puncture.  An  aspirating  needle  4  cm.  long  should  be  used. 
This  is  plunged  directly  into  the  bladder  at  a  point  about  1  cm.  above 
the  pubes.  The  urine  is  aspirated  and  suction  continued  as  the  needle 
is  withdrawn. 

The  danger  of  infection  along  the  track  of  the  needle  is  slight. 

Aspiration  is  preferable  to  puncture  only  when  the  relief  of  reten- 
tion is  required  but  for  a  few  hours.  For  more  prolonged  drainage  a 
single  puncture  is  preferable  to  repeated  aspirations. 

SUPRAPUBIC  CYSTOTOMY 

Entrance  to  the  bladder  may  be  gained  by  the  perineal  route  or 
by  direct  opening  of  the  bladder  through  a  suprapubic  incision.  The 
latter  operation  was  considered  by  the  older  surgeons  to  have  the  higher 
mortality.  But  asepsis  during  the  operation  and  care  in  the  manage- 
ment of  the  drainage  thereafter  has  rendered  the  mortality  negligible. 

Anesthesia. — Suprapubic  drainage  can  be  done  under  local  anes- 
thesia. 

Preparation  of  the  Patient. — The  patient  is  shaved  and  cleaned  as 
for  a  major  operation,  hexamethylenamin  is  given  in  1  gram  doses 
for  one  or  two  days  preceding  operation,  and  the  bladder  is  prepared 
either  by  continuous  catheterization  or  by  daily  irrigation  with  silver 
nitrate  solution  in  strength  of  from  1  in  3  to  1  in  5,000. 

The  Incision. — An  incision  is  made  in  the  linea  alba  at  least  6 
centimeters  in  length  beginning  just  above  the  pubes.  In  separating 
the  recti  the  pyramidales  are  cut  through.  The  recti  are  then  retracted, 
revealing  the  transversalis  fascia.  This  is  drawn  upward  to  make  it 
tense,  and  divided  transversely  close  to  the  upper  border  of  the  sym- 
physis (Fig.  162).  Then  the  fascia  and  subjacent  fat  are  rolled  up- 
ward away  from  the  bladder.  In  this  layer  of  fat  is  the  peritoneum 
which  is  not  seen  unless  it  is  accidentally  torn. 

As  the  bladder  comes  into  view  it  is  recognized  by  the  parallel  verti- 
cal muscle  fibers.  It  is  still  further  identified  by  the  large  veins  running 
in  the  same  direction  as  the  muscle  fibers.  As  the  fat  is  rolled  away 
from  the  bladder  it  will  be  noted  that  it  adheres  to  this  organ  in  the 
median  line.  This  is  due  to  the  presence  of  the  urachus.  This  adhesion 
may  usually  form  the  limit  of  our  denudation,  but  if  an  extensive 
exposure  of  the  bhidder  is  required  the  urachus  may  be  divided  and 
tied   (for  it  usually  contains  an  artery). 

Distention  of  the  Bladder — It  is  not  my  practice  to  distend  the 
bladder  at  all  unless  there  is  some  difficulty  in  locating  it,  for  the  pour- 


SUPRAPUBIC  OPERATIONS 


715 


ing  out  of  fluid  from  the  incision  in  the  bladder  is  a  minor  inconvenience 
and  delay  in  the  operation.  It  is  customary,  however,  to  distend  the 
bladder  either  with  sterile  water  or  else  with  air.  Inasmuch  as  rup- 
ture of  the  bladder  has  several  times  resulted  from  distention  of  this 
organ  before  it  was  incised,  and  inasmuch  as  the  slowly  rising  globe 
of  bladder  as  the  water  fills  it  adds  precision  to  the  surgeon's  knowledge 


Fig.  162. — Exposure  of  the  Bladder. 

of  the  position  of  the  viscus,  it  is  better  that  it  should  be  distended 
only  after  the  parietes  have  been  divided. 

Distention  with  air  introduced  by  means  of  the  pump  of  a  Paquelin 
cautery  was  much  in  favor  a  few  years  ago.  Over-distention  and  rup- 
ture are  doubtless  less  likely  to  occur  when  air  is  employed  than  with 
fluid.  Nicolich  and  Marion  ^  have  both  reported  deaths  occurring  as 
the  air  was  being  injected  into  the  bladder  and  before  the  operation 
had  begim.     The  air  was  found  in  the  great  vessels  and  in  the  heart. 

^Jour.  d'Urol.,   1913,  iii,  44. 


716  ANATOMY  OF  THE  BLADDER— SUPRAPUBIC  OPERATIONS 

Incision  of  the  Bladder. — As  soon  as  the  bladder  muscle  is  recog- 
nized and  well  exposed  this  organ  is  caught  on  each  side  of  the  median 
line  by  a  skin  hook  (or  bv  a  suture  introduced  with  a  curved  needle). 
With  the  bladder  wall  thus  distended  on  each  side  a  vertical  median 
incision  about  3  centimeters  long  is  made  in  it.    If  the  bladder  has  not 


Fig.  163. — Incision  of  the  Bladdeb. 

been  distended  one  must  exercise  a  little  care  to  get  well  through  the 
mucous  membrane.  If  it  has  been  distended  one  must  await  the  out- 
flow of  fluid.  Great  care  should  be  exercised  not  to  incise  the  bladder 
too  far  upward  toward  the  umbilicus  for  fear  of  opening  the  peritoneum 
and  bladder  at  the  same  time.  Opening  the  peritoneum  before  the 
bladder  is  a  matter  of  no  consequence;  opening  both  together  is 
dangerous. 

As  soon  as  the  mucosa  of  the  bladder  is  identified  this  is  seized  on 
each  side  by  Kocher  clamps  and  the  operation,  whatever  it  may  be, 


SUPRAPUBIC  OPERATIONS 


717 


proceeded  with  while  the  skin  hooks  are  disengaged  from  the  bladder 
muscle. 

Suture  of  the  Bladder, — The  bladder  may  be  closed  with  or  without 
drainage.  If  there  is  no  retention  and  no  great  hemorrhage  within  the 
organ  it  is  safe  to  suture  without  drainage  even  though  there  be  con- 
siderable infection.  A  very  satisfactory  suture  is  that  of  Lower.^ 
This  is  practically  a  subcuticular  suture  in  the  bladder  muscle  just 
beneath  the  mucosa. 
When  this  has  been 
placed  from  end  to 
end  of  the  incision 
one  returns  with  an 
over-and-over  suture 
penetrating  all  the 
layers  except  the 
mucosa. 

The  suture  should 
be  of  the  finest  chro- 
mic catgut.  Plain 
catgut  does  not  hold 
quite  long  enough 
and  linen  or  silk  will 
result  in  permanent 
fistula  with  incrus- 
tation of  the  suture  even  though  it  does  not  penetrate  the  mucosa. 

If  drainage  is  to  be  employed  the  bladder  may  be  inverted  about 
the  tube  by  Gibson's  method  as  shown  in  the  accompanying  illustra- 
tion (Fig.  164). 

When  suprapubic  drainage  is  employed  the  size  of  the  tube  should 
be  regulated  in  accordance  with  the  thickness  of  the  fluid  that  is  to 
issue  from  it.  Thus  after  prostatectomy  an  enormous  Freyer  tube 
should  be  used  in  order  to  take  care  of  the  blood  clots  readily.  The 
tube  should  always  be  left  in  the  upper  end  of  the  bladder  wound  and 
the  lower  end  sutured. 

The  indwelling  catheter  may  often  be  employed  with  advantage  to 
provide  urethral  drainage  whether  a  tube  is  left  in  the  suprapubic 
wound  or  not. 

Suture  of  the  Parietes — After  the  bladder  wound  has  been  sutured 
the  vault  of  the  bladder  should  be  attached  to  the  rectus  muscles  by 
a  plain  catgut  suture  in  order  to  prevent  hernia  through  bulging  of  the 
peritoneum  between  the  bladder  and  the  muscles.  The  muscles,  the 
anterior  sheath  of  the  rectus,  and  the  skin  are  then  closed,  leaving 
space  for  a  cigarette  drain  to  go  to  the  line  of  suture  in  the  bladder 

^Cleveland  Med.  Jour.,  1910,  ix,  706. 


Fig. 


164. — Inversion   of    Bladder    Wall.    About    Tube. 
(Gibson's  Method.) 


718    ANATOMY  OF  THE  BLADDER— SUPRAPUBIC  OPERATIONS 

(below  the  tube  if  one  is  employed)  in  order  to  drain  the  space  of 
Retzius.  Under  no  circumstances  should  the  muscles  be  closed  through- 
out: drainage  is  always  required. 

Complications  During  the  Operation. — Opening  of  the  peritoneum 
before  the  bladder  is  opened  is  remedied  by  suture.  Indeed,  if  the 
peritoneum  is  adherent  one  may  deliberately  open  it  high  up  in  the 
abdominal  wound,  put  one's  finger  into  the  pouch  of  peritoneum,  and 
thus  much  more  readily  separate  this  from  the  bladder;  after  which 
the  wound  in  the  peritoneum  is  sutured  and  the  bladder  opened. 
If  peritoneum  and  bladder  are  opened  simultaneously  the  former  must 
be  thoroughly  dried  before  it  is  sutured. 

Hemorrhage  from  the  vessels  of  the  bladder  wall  may  prove  incon- 
venient but  can  readily  be  controlled. 

Postoperative  Treatment. — Hexamethylenamin  is  administered  in 
1  gram  doses,  beginning  as  soon  as  possible  after  operation.  Murphy 
drip  is  employed  to  encourage  kidney  action.  The  cigarette  drain  is 
removed  in  twenty-four  hours  if  tube  drainage  has  been  used,  forty- 
eight  hours  if  the  bladder  has  been  sewed  tight.  In  order  to  hasten  the 
healing  of  the  wound  the  tube  should  be  removed  in  twenty-four  hours 
or  as  soon  thereafter  as  the  bleeding  stops  and  replaced  by  a  smaller 
one  attached  to  a  suction  apparatus.  If  continuous  suction  is  ob- 
tainable this  is  usually  a  rather  forceful  proceeding  and  in  order  to 
spare  the  tissues  of  the  wound  the  drainage  tube  must  be  surrounded  by 
a  loosely  fitting  outside  tube  of  rubber,  perforated  with  several  holes. 
Otherwise  the  tissues  of  the  patient  are  made  sore  by  being  sucked 
into  the  holes  of  the  actual  drainage  tube.^  Where  continuous  suction 
is  not  to  be  had  an  admirable  apparatus  is  that  of  Davis  -  which  consists 
essentially  of  a  very  large  bottle,  rubber-stoppered,  with  two  tubes 
let  through  the  stopper.  One  of  these  is  used  for  aspiration;  through 
it  the  bottle  is  attached  to  a  Sprengel  air-pump  and  the  air  sucked  out 
until  the  tube  collapses.  The  other  tube  is  then  attached  to  a  second 
bottle,  smaller,  rubber-stoppered,  and  also  with  two  outlet  tubes.  Be- 
tween the  two  bottles  a  capillary  tube  of  great  fineness  permits  the  air 
to  escape  from  the  smaller  into  the  larger  bottle  only  by  imperceptible 
degrees,  so  that  the  aspiration  of  the  larger  bottle  will  suffice  to  keep 
continuous  suction  going  in  the  smaller  one  for  twenty-four  hours  or 
more.  The  second  tube  in  the  smaller  bottle  is  led  into  the  suprapubic 
wound. 

The  advantage  of  this  continuous  suction  is  twofold:  In  the  first 
place,  it  expedites  healing;  in  the  second  place,  it  keeps  the  patient 
clean  while  healing  is  going  on.  There  is  no  soiling  of  dressings  and 
bed,  no  irritation  of  the  skin,  no  sloughing  of  the  wound.     If  a  very 

»Cf.  Kenyon,  Surg.,  Gyn.  4-  Ohstet.,  July,  1913,  p.  115. 
*Jour.  A.  M.  A.,  May  27,  1916. 


SUPRAPUBIC  OPERATIONS  719 

large  tube  is  used  at  first  the  caliber  of  tlie  succeeding  tubes  is  dimin- 
ished from  time  to  time  as  rapidly  as  the  wound  appears  to  heal.  The 
only  other  attention  it  will  need  is  the  cutting  down  of  granula- 
tions. 

Finally  when  the  wound  is  too  small  for  an  ordinary  catheter  to  lie 
loosely  in  it  the  suction  may  be  advantageously  replaced  by  an  in- 
dwelling urethral  catheter. 

Postoperative  Complications. — One  should  be  very  careful  about 
employing  continuous  irrigation  through  the  suprapubic  tube.  Many 
cases  of  postoperative  pelvic  abscess  are  due  to  the  irrigating  fluid 
being  forced  out  through  the  bladder,  failing  to  escape  between  the 
muscles,  and  so  forcing  its  way  into  the  cellular  tissue  beneath  the 
belly  wall. 

A  much  more  common  and  a  very  annoying  postoperative  com- 
plication is  staphylococcus  infection  of  the  wound.  The  wound  be- 
comes covered  with  slough;  all  the  adjacent  properitoneal  fat  and  the 
edges  of  the  anterior  sheath  of  the  rectus  slough  away  and  the  leathery 
slough  covers  all  the  wound.  This  infection  does  not  occur  if  continu- 
ous suction  is  employed.  When  it  does  happen,  however,  it  may  be 
checked  if  a  tube  can  be  fitted  so  well  to  the  wound  as  to  keep  the  urine 
from  it.  This  can  usually  not  be  done,  but  some  help  may  be  expected 
from  the  use  of  the  indwelling  urethral  catheter.  Saturated  solution 
of  argyrol  makes  the  most  efficient  bactericide  for  application  to  the 
wound,  while  the  bladder  should  be  irrigated  at  least  twice  a  day  with 
as  strong  a  solution  of  argyrol  as  the  patient  can  bear. 

Persistent  suprapubic  fistula  depends  essentially  upon  urethral 
obstruction.  If  the  urethra  is  free  the  belly  wound  will  close.  Fistula 
is  encouraged,  however,  by  loss  of  tissue  in  the  abdominal  wall  (due 
to  inflammation  or  repeated  operation),  and  also  by  malposition  of 
the  wound  in  the  bladder.  If  the  tube  is  sutured  into  the  bladder  near 
its  neck  this  encourages  a  permanent  fistula.  One  may  encourage  the 
healing  of  the  fistula  by  keeping  it  clear  from  slough,  cutting  down 
granulations,  and  the  application  of  the  indwelling  catheter  in  the 
urethra. 

SUPRAPUBIC  LITHOTOMY 

Most  stones  may  be  quite  readily  removed  through  a  suprapubic 
incision  by  means  of  the  familiar  sponge  holder.  Large  stones,  however, 
require  the  lithotomy  forceps ;  an  instrument  whose  blades  resemble 
those  of  the  obstetrical  forceps  and  serve  the  same  purpose. 

The  incision  in  the  bladder  wall  should  be  made  as  small  as  possible 
so  that  it  may  be  sutured  tight  after  the  operation.  If  the  stones  are 
to  be  removed  under  a  local  anesthetic  one  must  not  forget  to  anesthetize 
the  interior  of  the  bladder  as  well  as  its  wall  and  the  parietes. 


720    ANATOMY  OF  THE  BLADDER— SUPRAPUBIC  OPERATIONS 


SUPRAPUBIC  SECTION  FOR  TUMOR 

The  Incision, — The  Trendelenburg  position  should  be  employed 
and  the  parietes  opened  by  the  usual  vertical  incision  which  in  this  in- 
stance should  extend  as  high  as  the  umbilicus.  Before  the  bladder  is 
opened  its  wall  is  freed  much  more  extensively  than  usual  by  division  of 
the  urachus  and  separation  of  the  peritoneum  above 
this  (unless  these  tissues  are  involved  in  the  growth). 
If  the  bladder  has  been  distended  with  fluid  this  is 
now  permitted  to  escape  through  the  urethral  catheter 
in  order  to  soil  the  wound  as  little  as  possible  with 
pieces  of  detached  tumor.  The  bladder  wall  is  freed 
quite  widely  so  that  it  can  practically  be  brought  out- 
side the  abdomen  and  incised  at  a  point  where  a  pre- 
vious cystoscopy  has  shown  that  there  is  doubtless  no 
tumor.  Previous  to  the  incision  the  surrounding  tis- 
sues are  walled  off  by  gauze.  The  interior  of  the 
bladder  is  then  very  gently  retracted  and  the  surgeon 
decides  whether  he  intends  to  continue  his  operation 
intra-  or  extraperitoneally.  If  intraperitoneally, 
great  care  is  taken  to  dry  the  bladder  of  its  contained 
urine  or  irrigation  fluid  before  opening  the  peritoneal 
cavity.  Then  the  peritoneum  is  boldly  opened  in  the 
median  line,  the  intestines  walled  off  and  the  bladder 
attacked.  Fortunately  (as  was  first  noted  by  Bovee) 
the  Trendelenburg  position  practically  inhibits  the 
excretion  of  urine  from  the  ureters  into  the  bladder 
so  that  little  soiling  may  be  anticipated  from  this 
cause. 

Squier  ^  suggested  the  following  ingenious  way  of 
identifying  the  various  structures  about  the  bladder : 


Fig.     165. — Lithot- 
omy Forceps. 


The  patient  is  placed  in  extreme  Trendelenburg  position,  the  anterior  ab- 
dominal wall  incised  from  the  symphysis  to  a  point  one  inch  above  and  to  the 
left  side  of  the  umbilicus.  The  peritoneum  may  be  opened  or  the  whole  operation 
may  be  perfoi-med  extraperitoneally  as  follows : 

The  urachus  is  grasped  with  a  Barret  intestinal  forceps  and  traction  is 
made  upward,  throwing  into  relief  the  obliterated  hypogastric  arteries  as  they 
divaricate  to  enter  the  true  pelvis.  The  left  obliterated  hypogastric  artery  is 
grasped  with  forceps  and  traction  made  upward  and  to  the  right.  By  blunt 
dissection  between  the  hypogastric  artery  and  the  lateral  wall  of  the  pelvis,  the 
vas  deferens  is  brought  into  view  as  it  courses  along  the  pelvic  wall  to  the 
inner  side  of  the  obliterated  hypogastric  artery. 

With  a  blunt  hook  passed  along  the  vas,  the  pelvic  ureter  is  uncovered,  the 
ureter  being  crossed  on  its  inner  side  by  the  vas  deferens.    Any  radical  technique 

^Surg.,  Gyn.  #  Obstet.,  July,  1914,  91. 


SUPRAPUBIC  OPERATIONS  721 

directed  to  the  extirpation  of  neoplasm  must  have  as  its  essential  point  the  two 
ureters  exposed  and  constantly  in  view. 

Divide  the  urachus  close  to  the  summit  of  the  bladder  and  draw  the 
bladder  downward  toward  the  symphysis.  If  the  peiitoneum  is  not  already 
infiltrated,  divide  freely  including  the  pouch  of  Douglas,  mobilizing  the  entire 
bladder  except  the  pubovesical  attachment.  //  the  iDeritoneum  is  found  firmly 
attached  and  already  the  seat  of  malignant  attachment,  this  area  is  left  undis- 
turbed and  a  wide  encircling  incision  is  made  about  the  infiltrated  peritoneum. 

The  divided  lamella  of  j^eritoneum  is  carefully  attached  to  the  upper  end 
of  the  abdominal  incision,  so  that  for  further  operative  purposes  the  peritoneal 
cavity  is  closed. 

A  one-inch  incision  is  made  in  the  bladder  high  up  in  the  posterior  surface 
for  inspection  of  the  viscus. 

The  neoplasm  is  excised  en  masse,  together  with  a  Avide  margin  of  healthy 
uninvaded  tissue  comprising  the  entire  thickness  of  the  bladder  wall.  If  the 
ureter  is  atfected  it  is  divided  above  the  growth,  and  the  distal  portion  is  re- 
moved with  the  tumor. 

The  hiatus  of  the  bladder  wall  is  partially  repaired  with  a  Connell  intes- 
tinal suture;  a  stab-wound  is  made  through  the  bladder  wall  at  a  point  approxi- 
mating the  normal  ureteral  opening,  and  the  proximal  end  of  the  divided  ureter 
drawn  through  this  opening  by  a  thin  dressing  forceps. 

The  ureter  is  anchored  to  the  bladder  wall,  allowing  one-half  inch  to 
protrude,  two  flaps  being  dissected  and  anchored  on  the  inner  surface  of  the 
bladder.  The  remainder  of  the  bladder  is  closed,  and  through  a  stab-wound 
high  on  the  anterior  surface  of  the  viscera  a  No.  26  F.  soft-rubber  catheter  is 
inserted  and  sutured  in  situ. 

The  final  step  is  the  reposition  of  the  peritoneum  over  the  vesical  suture 
line  and  an  accurate  closure  of  the  peritoneum,  care  being  exercised  not  to 
approximate  the  peritoneal  and  bladder  suture  lines.  A  cigarette  drain  is 
inserted  into  the  back  lateral  space.  In  addition,  a  self-retention  catheter  is 
inserted. 

Small  tumors  confined  to  the  vault  of  the  bladder  may  be  excised 
with  a  goodly  section  of  surrounding  normal  bladder  wall  by  a  simpler 
technic.  Hagner  suggests  that  the  first  incision  be  guided  by  a  cysto- 
scope  within  the  bladder  so  that  the  neoplasm  itself  shall  not  be  incised. 
A  cystoscopy  before  the  operation  will,  however,  often  place  the  tumor 
accurately  enough  so  that  it  can  be  avoided  without  this  complication. 

Beer  removes  all  tumors  by  the  actual  cautery.  For  multiple 
paplV'.omata  he  employs  thorough  surface  cauterization  through  a 
suprapubic  opening.  For  infiltrating  growths  he  first  destroys  the 
growth  with  the  actual  cautery,  then  excises  its  base  widely,  still 
using  the  cautery. 

Tumors  involving  the  trigone,  and  requiring  resection  of  this, 
call  for  reimplantation  of  the  ureter  in  the  most  convenient  portion 
of  the  remaining  bladder  wall. 

Practically  all  of  the  bladder  may  be  excised  excepting  the  trigone 
with  the  expectation  that  the  remaining  portion  of  the  organ  will 
dilate  sufficiently  to  retain  several  ounces  of  urine. 

Extensive  growths  are,  however,  not  susceptible  to  cure.  •  The  best 


722  ANATOMY  OF  THE  BLADDER— SUPRAPUBIC  OPERATIONS 

we  can  hope  for  is  a  local  removal  whicli  shall  comfort  the  patient  and 
prolong  life.     He  will  die  of  metastasis. 

The  statistics  of  suprapubic  removal  of  tumors  are  relatively  un- 
trustworthy in  the  sense  that  no  two  operators  consider  precisely  the 
same  type  of  tumors  amenable  to  intravesical  removal.  Those  who  re- 
port the  best  results  from  suprapubic  section  are  usually  the  ones  most 
reticent  in  the  use  of  intravesical  treatment. 

The  after-treatment  and  complications  following  resection  of  the 
bladder,  whether  intra-  or  extraperitoneal,  do  not  differ  materially 
from  those  of  simple  cystotomy  with  the  exception  of  the  greater  shock, 
the  liability  to  renal  infection  from  transplantation  of  the  ureter,  and 
the  increased  possibility  of  peritonitis. 

TOTAL  CYSTECTOMY 

Total  cystectomy  for  tumor  should  be  performed  only  after  preced- 
ing disposal  of  the  ureters  in  the  skin  or  in  the  intestines.  After  the 
patient  has  recovered  from  this  operation  the  bladder  is  removed  by  an 
operation  consisting  of  two  major  steps.  In  the  first  the  patient  is 
put  in  the  extreme  lithotomy  position,  and  the  operation  begun  as 
though  for  removal  of  the  cancerous  prostate  (page  749).  The  mem- 
branous urethra  is  divided  and  the  prostate  freed  up  to  the  neck  of  the 
bladder.  This  is  not  incised,  however,  but  the  perineal  wound  is 
packed,  the  patient  let  down  into  .the  Trendelenburg  position,  for  the 
second  stage  of  the  operation.  This  consists  in  freeing  the  bladder  from 
its  surrounding  attachments  through  a  long  vertical  intraperitoneal  in- 
cision. ISTo  great  difficulty  is  experienced  until  the  base  of  the  bladder 
is  reached.  Here  the  oozing  may  be  considerable  between  the  seminal 
vesicles  and  the  rectum ;  but  with  a  sufficiently  large  incision  this  is 
easily  controlled.  Effort  is  made  to  spare  enough  of  the  peritoneum 
so  that  the  anterior  and  posterior  flaps  may  be  brought  together  at  the 
close  of  the  operation.  Enlarged  glands  should  be  excised  along  the 
course  of  the  internal  iliac  artery. 

The  operative  mortality  of  total  cystectomy  is  very  high,  and  the 
ultimate  mortality  still  higher.  Eor  a  growth  that  is  so  large  as  to 
require  total  cystectomy  almost  inevitably  has  led  to  glandular  metas- 
tases which  defy  eradication.  We  have  not  as  yet  sufficient  evidence 
at  hand  to  decide  the  value  of  an  extended  search  for  enlarged  lym- 
phatics in  the  pelvis  and  along  the  iliac  vessels. 

SUPRAPUBIC    CYSTOSTOMY 

Permanent  suprapubic  drainage  of  the  bladder  is  performed  by 
median  suprapubic  cystotomy,  followed  by  suture  of  the  wound  in  the 
bladder  to  the  wound  in  the  skin. 


SUPRAPUBIC  OPERATIONS 


723 


Postoperative  Treatment. — The  drainage-tube  is  retained  in  place 
until  the  wound  lias  healed.  It  is  then  removed  and  the  patient  pro- 
tected hy  a  hypogastric  urinal  or  tube  (Fig.  166). 


EXCISION  OF  DIVERTICULUM 

The  excision  of  small  and  relatively  uninflamed  diverticula  is  not 
a  very  difficult  matter,  but  the  larger  and  more  chronically  inflamed 
sacs  become  so  adherent  to  the  lateral  and  posterior  pelvic  walls  and 
to  the  rectum  that  their  total 
excision  is  extremely  tedious 
and  trying,  both  to  the  sur- 
geon and  to  the  patient. 

Before  operation  the  gen- 
eral outlines  of  the  diverticula 
should  be  studied  by  cystog- 
raphy. 

Squier's  technic  for  resec- 
tion of  the  bladder  (p.  720) 
may  be  advantageously  fol- 
lowed as  it  usually  discloses 
the  position  of  the  ureters 
quite  accurately.  But  if  the 
ureter  is  hidden  by  a  large 
diverticulum  it  is  usually  bet- 
ter to  seek  it  extraperitoneally 
at  the  point  where  it  crosses 
the  iliac  bifurcation  and  to 
follow  it  .  down  toward  the 
bladder.  It  is  essential  that 
the  relation  of  the  ureter  to 
the  diverticulum  be  thus  rec- 
ognized before  excision  of  the 
sac     is     attempted.       Having 

thus  identified  the  ureters  and  widely  freed  the  bladder  the  latter  is 
opened  in  the  median  line  and  the  diverticulum  stuffed  full  of  gauze. 
Its  upper  portions  are  then  rapidly  freed  from  the  surrounding  cellular 
tissue,  its  deeper  portions  more  carefully  dissected  away.  The  orifice 
of  the  diverticulum  into  the  bladder  is  then  excised  and  the  hole  thus 
made  in  the  bladder  wound  sutured  in  two  rows  with  chromic  catgut  not 
penetrating  the  mucous  membrane.  The  bladder  and  abdominal  walls 
are  then  closed  as  above  described. 

If  the  ureter  opens  just  inside  the  edge  of  the  diverticulum  a  flap 
may  be  cut  out  so  that  this  flap  containing  the  ureter  orifice  has  a 


k--= 


Fig.  166. — Permanent  Suprapubic  Drainage 
Tube.  A  and  B  are  disks,  the  former  at  least 
8  cm.  in  diameter. 


724  ANATOMY  OF  THE  BLADDER— SUPRAPUBIC  OPERATIONS 

median  attachment  to  the  bladder  wall.  Its  cut  edges  are  sutured  so 
as  to  close  the  defect  left  by  removal  of  the  remainder  of  the  diverticu- 
lum. But  if  the  ureter  opens  elsewhere  in  the  diverticulum  or  is  acci- 
dentally cut  in  its  removal  it  must  be  reimplanted  in  the  bladder. 


CHAPTER  LXXIY 


MEDIAN  PERINEAL  SECTION 


Position  of  the  Patient. — The  patient  is  placed  in  the  so-called  lithot- 
omy position,  npon  his  back,  with  thighs  and  knees  flexed  at  an  acute 
angle  and  held  in  this  position  by  leg  supports. 

Field  of  Operation. — The  field  of  operation  to  be  prepared  antisep- 
tically  includes  the  pubes,  the  external  genitals,  the  perineum,  and  the 
adjoining  portions  of  the  thighs  and  buttocks.  These 
are  prepared  by  the  usual  routine  of  shaving,  etc.  It 
is  to  be  remembered  that  the  sensitive  skin  of  the 
scrotum  is  gTeatly  irritated  by  a  soap  poultice;  if 
used  it  must  not  be  left  in  place  for  more  than  three 
hours.  In  scrubbing  the  patient  upon  the  table,  spe- 
cial care  should  be  taken  to  clean  the  preputial  cav- 
ity and  to  irrigate  the  bladder  and  urethra  with 
nitrate  of  silver  (1:  5,000)  or  permanganate  of  po- 
tassium (1 :  3,000).  It  is  better  to  leave  some  of  the 
fluid  in  the  bladder,  in  order  that  this  antiseptic  may 
run  out  from  the  wound  during  the  operation. 

Special  Instruments  Required. — A  grooved 
urethral  staff,  a  sharp-pointed  curved  bistoury,  and  a 
perineal  tube.  The  perineal  tube  is  a  soft-rubber 
tube  with  'terminal  and  lateral  eyes,  to  the  tip  of 
which  may  be  sewed  the  tip  of  a  soft-rubber  catheter. 
The  drainage-tube  should  be  size  28  or  30  French, 
the  catheter  15  or  16  French. 

Instruments  Employed  if  Local  Anesthesia  Is 
Used — The  urethra  is  anesthetized  by  the  method 
employed  in  cystoscopy.     In  place  of  the  bistoury  the  surgeon  requires 
a  scalpel,  artery  clamps,  grooved  director,  and  female  catheter,  and  the 
hypodermic  syringe,  needle,  and  solution. 

The  Operation  under  General  Anesthesia — Tlie  operation  can 
readily  be  done  in  two  minutes,  sometimes  in  one. 

The  grooved  staff  is  lubricated  and  introduced  well  into  the  bladder 
to  make  sure  that  its  point  has  passed  the  membranous  urethra.  3t 
is  then  withdrawn  and  held  by  an  assistant  in  such  a  manner  that 
its  curve  projects  forcefully  against  the  perineum. 

725 


Fig.  167. — Perineal 
Tube  with  Ter- 
minal AND  Later- 
al Eyes. 


726  MEDIAN  PERINEAL  SECTION 

The  surgeon  feels  the  staff  with  the  forefinger  of  his  left  hand  and 
plunges  the  curved  bistoury  into  the  skin  of  the  perineum  in  the 
median  line  about  5  cm.  in  front  of  the  anus,  driving  the  point  of  the 
knife  directly  into  the  gToove  of  the  staff  just  where  it  begins  to  curve 
away  from  the  perineum  toward  the  bladder. 

As  soon  as  the  knife  is  felt  to  strike  the  staff  it  is  pushed  inward 
along  this  instrument  for  about  2  cm.  and  then  drawn  outward  and 
backward  in  such  a  manner  as  to  make  an  incision  through  the  urethral 
mucosa,  the  overlying  tissues,  and  the  skin,  just  large  enough  to  admit 
the  surgeon's  finger.  As  the  knife  is  withdrawn,  the  finger  is  introduced 
in  its  place  and  feels  the  metal  staff  within.  This  instrument  is  then 
carefully  withdrawn,  and  as  its  tip  passes  from  under  the  surgeon's 
finger,  he  presses  this  finger  forward  into  the  bulbous  urethra,  guided 
by  the  roof  of  the  urethra  (according  to  the  classical  description,  the 
membranous  urethra  should  be  opened,  but  this  is  never  done  without 
very  careful  preliminary  dissection — and  incision  of  the  bulb  is  entirely 
harmless) . 

The  tight  ring  of  the  cut-off  muscle  is  felt,  and  into  this  the  finger 
is  firmly  but  gently  insinuated,  thence  into  the  prostatic  urethra  and 
into  the  bladder.  These  regions  are  investigated  rapidly  for  whatever 
diseased  condition  is  supposed  to  be  present.  This  investigation  may  be 
assisted  by  counterpressure  from  a  finger  in  the  rectum  or  from  a  hand 
on  the  hypogastrium. 

At  the  close  of  the  operation  the  perineal  tube  is  gTasped  with  a 
dressing  forceps  in  such  a  way  as  to  bend  its  tip  upward  so  that  this 
may  not  catch  in  the  urethral  floor  at  the  bladder  neck.  The  bladder 
is  then  irrigated  through  this  tube  both  to  clear  it  of  clots  and  to 
prove  that  the  tube  is  properly  placed  to  drain  the  bladder. 

The  tube  is  held  in  place  by  a  silkworm  giit  suture,  piercing  the 
skin  and  wrapped  several  times  about  the  tube. 

It  will  be  noted  that  the  bladder  is  readily  cleared  of  blood  unless 
the  internal  sphincter  has  been  torn,  but  that  a  free  venous  ooze  drips 
from  the  perineal  wound.  The  wound  should  only  be  drained  by  a 
wick  of  rubber  tissue,  never  packed  with  gauze,  no  matter  how  severe 
the  hemorrhage,  for  the  counterpressure  of  the  dressing  upon  the 
perineum  readily  stops  this,  while  removal  of  the  gauze  packed  in 
the  urethra  is  always  painful  and  sometimes  excites  secondary  hemor- 
rhage that  requires  replacement  of  the  tube  and  repacking  of  the 
wound. 

A  dressing  of  gauze  is  then  placed  about  the  tube  against  the 
perineum,  to  l)e  held  in  place  by  a  T-bandage.  It  is  best  to  use  the  so- 
called  "female"  T-bandage  with  a  single  central  piece,  which  piece  is 
split  up  just  far  enough  back  not  to  interfere  with  the  perineal  tube.  Its 
two  ends  are  laid  over  the  dressing  on  each  side  of  the  tube,  crossed  in 


MEDIAN  PERINEAL  SECTION 


727 


front  of  tlie  tube,  enougli  extra  gauze  laid  transversely  underneatli  the 
scrotum  to  support  this  well,  and  the  two  ends  of  the  T-bandage  carried 
up  and  pinned  to  the  waistband  in  front. 

The  patient's  legs  are  then  let  down  from  the  supports,  and  the  ef- 
ficiency of  the  perineal  tube  tested  by  injection  of  salt  solution  or  boric 
acid  solution.  If  it  does  not  flow  out,  the  tube  is  not  inside  the  bladder, 
or  is  plugged  with  clots.  If  it  flows  out  in  an  irregTilar  and  intermit- 
tent manner,  suddenly  stopping  off  and  beginning  again,  the  tube  has 
been  inserted  too  far. 
By  pushing  in,  pull- 
ing out,  or  removing 
the  tube  to  examine 
it  for  clots,  it  is  fi- 
nally placed  at  the 
proper  position.  In 
order  to  avoid  such 
manipulations  after 
operation,  the  tube, 
when  first  placed, 
while  the  patient  is 
still  upon  the  operat- 
ing table  with  his 
legs  in  the  air,  should 
be  inserted  just  far 
enough  to  run 
smoothly  and  then 
pushed  in  about  2 
cm.  farther,  and 
fixed  in  place. 

Operation  under 
Local    Anesthesia. — 
The  urethra  is  anes- 
thetized as  for  cystos- 
copy (p.  51),  and  at  least  fifteen  minutes  permitted  to  elapse  for  this 
to  take  effect.     This  time  is  employed  in  the  final  cleaning  of  the  opera- 
tive field,  getting  the  patient  into  position,  and  beginning  the  infiltra- 
tion anesthesia. 

The  skin  of  the  perineum  is  anesthetized  in  the  median  line  for  a 
distance  of  4  to  6  cm.  forward  from  a  point  3  cm.  in  front  of  the  anus. 
The  skin  is  immediately  incised,  and  this  incision  carried  down  to  the 
muscles  surrounding  the  urethra.  These  muscles  are  then  infiltrated 
in  the  median  line  and  laterally  backward,  so  as  to  surround  the  bulb 
of  the  urethra  with  a  layer  of  the  anesthetic.  Inasmuch  as  all  the 
nerves  run  forward,  the  anterior  portions  of  the  deeper  wound  need 


Fig.  168. — Median  Perineal  Section  under  Local  An- 
esthesia. Grooved  staff  seen  between  separated  borders 
of  incisions.  (Bryant.) 


728  .         MEDIAN  PERINEAL  SECTION 

only  be  anestlietized  in  the  median  line,  if  at  all.  Indeed,  Ilmer  ^  has 
obtained  adequate  anesthesia  by  injecting  the  internal  pudic  nerve  on 
each  side  just  posterior  to  the  ischial  tuberosity. 

The  grooved  staff  is  then  introduced  in  the  manner  already  described 
and  pressed  forward  into  the  perineum.  The  muscles  overlying  the 
urethra  are  divided  in  the  median  line,  and  after  them  the  spongy 
tissue  of  the  bulb.  One  or  two  arterial  branches  are  cut  and  may 
be  held  in  artery  clamps,  to  be  tied  after  the  operation  is  finished. 
The  oozing  from  the  bulb  is  neglected,  and  as  soon  as  the  staff  comes 
into  view  this  is  withdrawn  and  the  finger  introduced  into  the  urethra.^ 

Up  to  this  point  the  operation  should  be  entirely  painless ;  but  it  is 
often  difficult  to  force  the  cut-off  muscle  with  the  finger  without  causing 
the  patient  a  great  deal  of  pain.  This  may  be  obviated  by  a  whiff  of  gen- 
eral anesthetic,  or  sometimes,  but  not  always,  by  infiltration  around  the 
membranous  urethra  with  a  long  hypodermic  needle,  guided  by  the  finger 
in  the  rectum.  But,  inasmuch  as  the  muscle  may  be  rapidly  forced,  it 
is  often  wiser  to  tell  the  patient  that  one  is  about  to  hurt  him  for  an 
instant,  and  then  to  insert  the  finger  rapidly  into  the  posterior  urethra. 

After  the  finger  has  passed  the  membranous  urethra,  the  prostate 
and  the  neck  of  the  bladder  may  be  palpated  without  exciting  pain  so 
long  as  that  part  of  the  finger  in  the  grip  of  the  cut-off  muscle  is  not 
moved. 

The  operation  is  brought  to  a  close  in  the  manner  described  above. 
As  the  skin  incision  is  unnecessarily  long,  one  or  two  catgut  sutures 
should  be  taken  through  the  skin,  the  muscles,  and  the  incised  bulbous 
urethra  at  the  anterior  extremity  of  the  incision. 

After-treatment. — If  the  prostate  has  been  removed  or  the  bladder 
neck  otherwise  torn,  the  bladder  will  fill  with  clots  unless  continuous 
irrigation  is  used  from  a  tank  not  higher  than  a  foot  above  the  level 
of  the  bed,  in  which  is  kept  1  per  cent  boric  acid  solution  at  a  tempera- 
ture of  115°  F.  The  irrigation  is  managed  like  a  Murphy  rectal  drip, 
the  inflow  being  regulated  to  keep  the  color  of  the  fluid  a  light  pink. 
Continuous  irrigation  is  kept  up  until  the  fluid  has  flowed  clear  from 
the  bladder  for  several  hours. 

The  tube  is  removed  from  the  bladder  at  the  end  of  twenty-four  or 
forty-eight  hours,  unless  some  special  indication,  such  as  kidney  drain- 
age, calls  for  its  retention.  After  the  removal  of  the  tube,  the  wound 
is  irrigated  once  with  peroxid  of  hydrogen  and  water,  equal  parts. 

The  anterior  urethra  and  bladder  are  irrigated  daily,  both  before 
and  after  removal  of  the  tube,  with  boric  acid  or  permanganate  of  potas- 

^Centralbl.  f.  Gynec,  May  21,   1910. 

^The  inexperienced  surgeon  may  replace  the  staff  with  a  grooved  director,  and 
along  this  pass  a  female  catheter  from  which  urine  issues,  showing  it  to  be  in  the 
bladder. 


MEDIAN  PERINEAL  SECTION  729 

slum  solution.  As  soon  as  the  tube  is  removed,  the  patient  may  sit 
up  if  his  condition  permits.  On  account  of  the  wound  in  his  perineum 
he  will  have  to  sit  upon  a  rubber  ring. 

After  removal  of  the  tube  the  patient  usually  urinates  through  the 
perineal  wound  for  from  a  day  to  a  week  or  so.  Its  healing  may  be 
hastened  by  intelligent  care.  Thereafter  the  urine  begins  to  come  by 
the  urethra ;  but  from  time  to  time,  for  several  days,  the  perineal  wound 
may  burst  open,  permitting  a  gaish  of  urine  to  come  through  it,  and  fill- 
ing the  patient  with  despair.  But  he  may  be  reassured  by  the  state- 
ment that  such  an  accident  is  to  be  expected.  The  urine  remains 
purulent  for  several  weeks,  but  unless  there  is  considerable  inflammation 
of  the  bladder  or  retention  of  urine,  no  further  instrumentation  or  wash- 
ing of  the  urethra  or  bladder  is  employed.  It  is  quite  unnecessary  to 
pass  a  sound  unless  the  operation  revealed  stricture. 

Complications — Hemorrhage,  spasm,  and  infection  are  the  three 
complications  to  be  feared. 

Hemorrhage  does  not  occur  into  the  bladder  unless  the  bladder 
neck  has  been  torn.  It  does  no  harm  if  the  tube  and  the  bladder  are 
kept  clear  of  clots  by  continuous  irrigation.  The  bleeding  is  usually 
free  for  the  first  day,  after  which  it  decreases  rapidly. 

Bleeding  from  the  perineal  wound  is  unimportant  unless  packing 
has  been  inserted,  or  the  prostate  badly  torn. 

Spasm  of  the  bladder  is  excited  by  distention  of  the  organ  with  clots 
or  by  obstruction  or  slipping  of  the  tube.  The  spasm  may  also  be  set 
up  by  the  mere  presence  of  the  tube  or  of  packing  in  the  perineal  wound. 
Clots  may  be  removed  by  repeated  gentle  injections  and  aspirations  of 
hot  boric  acid  solution,  or  by  replacing  the  tube  with  a  litholapaxy  tube 
and  aspirator.  After  removal  of  clots  the  bladder  is  irrigated  with  a 
suspension  of  Squibbs  comp.  alum  powder  (1  part  in  10  of  hot  water) 
to  break  up  the  remaining  clots. 

If  the  spasm  is  due  to  the  mere  presence  of  the  tube,  the  patient 
should  be  kept  under  the  influence  of  narcotics  for  the  first  twenty-four 
hours,  and  if  spasm  persists  at  the  end  of  that  time  the  tube  must  be 
replaced  with  a  smaller  one  or  removed  entirely.  In  the  latter  event  the 
frequent  use  of  the  catheter  may  be  required. 

Infection  is  the  great  danger.  It  may  assume  any  of  the  forms  of 
urethral  or  urinary  fever.  Our  great  safeguards  are  water  and  hexa- 
methylenamin,  nitrate  of  silver  locally,  and  the  perineal  tube  to  supply 
adequate  drainage.  It  is  a  good  hospital  rule  that  if  the  patient  has  a 
chill  or  a  sharp  rise  of  temperature  while  the  tube  is  in  his  perineum, 
this  should  be  removed.  If  removal  of  the  tube  is  followed  by  a  chill 
no  account  need  be  taken  of  this  unless  it  is  repeated  or  the  temperature 
remains  up  for  more  than  twenty-four  hours.  In  that  ev^ent  a  small  tube 
should  be  replaced. 


730  '      MEDIAN  PERINEAL  SECTION 

PERINEAL  SECTION  FOR  PROSTATIC  ABSCESS 

The  incision  is  performed  in  the  manner  described  above.  The 
ungloved  index  finger  of  the  right  hand  is  inserted  into  the  prostatic 
urethra,  the  index  finger  of  the  left  hand  into  the  rectum  and  the  pros- 
tatic lobes  are  palpated  between  the  two.  They  are  torn  open  by  a 
gouging  motion  of  the  finger  within  the  urethra,  which  thus  lays  open 
the  foci  of  suppuration.  If  the  prostatic  lobe  has  not  yet  been  broken 
down,  but  contains  a  great  number  of  minute,  suppurating  foci,  it  will 
be  felt  as  a  spongy,  friable  tissue.  This  is  crushed  into  a  pulp  by  two 
or  three  sweeps  of  the  finger.  It  is  unnecessary  to  attempt  either  anti- 
septic irrigation  or  drainage  by  tube  or  gauze  in  the  prostatic  cavity. 
The  perineal  tube  is  inserted  as  usual  and  removed  at  the  end  of  twenty- 
four  hours.  The  perineal  wound  in  these  cases  usually  remains  open 
for  much  longer  than  usual. 

INTERNAL  AND  EXTERNAL  URETHROTOMY  WITH  A  GUIDE 

Uncomplicated  cases  of  urethral  stricture  may  require  internal 
urethrotomy,  external  urethrotomy,  or  the  two  together.  The  prepara- 
tion and  selection  of  anesthetic  for  such  cases  should  be  subject  to  the 
rules  of  renal  function  tests,  drainage  (by  preliminary  suprapubic  punc- 
ture or  by  perineal  section  without  general  anesthetic),  etc.,  laid  down 
for  prostatectomy. 

External  Urethrotomy. — The  "lithotomy"  position  is  employed,  a 
staff  or  filiform  introduced,  and  the  urethra  opened  upon  this  by  the 
scalpel  (not  the  bistoury.  Cf.  p.  726).  A  grooved  director  is  then 
inserted  alongside  of  the  filiform,  which  is  withdrawn,  and  the  stricture 
at  the  entrance  of  the  membranous  urethra  incised  upon  the  grooved 
director,  after  which  the  finger  is  inserted  into  the  bladder.  The  pulp 
of  the  index  finger  is  turned  upward  and  swept  along  the  roof  of  the 
urethra,  from  the  forward  part  of  the  bulb  back  into  the  prostatic 
portion,  and  if  any  lumps  of  scar  tissue  are  felt  in  this  region  they  are 
either  divided  or  cut  away.  Stricture  of  the  neck  of  the  bladder  is 
recognized  as  a  resisting  band  through  which  the  finger  will  not  pass. 
It  may  be  torn  through  and  dilated  with  the  finger.  If  the  bladder  neck 
is  torn,  continuous  irrigation  should  be  kept  up  for  forty-eight  hours. 

Internal  Urethrotomy — If  the  stricture  is  anterior  to  the  bulbous 
urethra,  and  impassable  to  any  instrument  except  a  filiform,  the  Maison- 
neuve  (Fig.  169)  urethrotome  must  be  employed.  This  is  screwed  on 
to  the  end  of  a  filiform,  pushed  into  the  bladder,  and  the  knife  pushed 
home.  If  the  stricture  of  the  anterior  urethra  will  admit  an  Otis  ure- 
throtome (Fig.  170),  this  is  introduced  (guided,  if  necessary,  upon  a 


INTERNAL  AND  EXTERNAL  URETHROTOMY  WITH  A  GUIDE  731 


filiform),  screwed  up  to  30  or  32  French,  and  the  knife  then  pulled  out. 
It  is  better  not  to  pull  the  knife  out  far  enough  to  cut  the  terminal  inch 
of  the  urethra,  but  to  reinsert  it  into  its  pocket,  revolve  the  urethrotome 
a  half  turn  and  cut  the  terminal  inch  on  the  floor. 

Internal  urethrotomy  should  always  be  performed  upon  the  roof  of 
the  urethra.  It  should  not  be  employed  for 
strictures  in  the  perineal  urethra,  or  at  the 
bulbomembranous  junction,  unless  perineal  sec- 
tion is  done  at  the  same  time. 
If  internal  urethrotomy  is 
done  without  external  urethrot- 
omy, no  instrument  should  be 
introduced  into  the  posterior 
urethra  at  the  time  of  the 
operation.  If  this  rule  is  ad- 
hered to,  there  is  no  danger  of 
urethral  chill  or  other  infec- 
tious complication  after  the 
operation. 

If  th3  liemorrhage  is 
alarming  and  does  not  soon 
cease,  it  may  be  checked  by 
bandaging  the  penis  and  mak- 
ing counterpressure  on  the 
perineum  against  a  medium- 
sized  catheter  in  the  urethra. 
Continental  authorities  em- 
ploy internal  urethrotomy  for 
strictures  in  the  perineal 
urethra,  and  in  order  to  avoid 
postoperative  infectious  com- 
plications always  insert  an  in- 
dwelling catheter  for  several 
days  after  operation. 

Internal  and  External 
Urethrotomy — ^AV  hen  the 
stricture  requires  both  internal 
and  external  urethrotomy,  two 
courses  are  open  to  the  sur- 
geon :  He  may  either  perform  Harrison's  operation — i.  e.,  an  internal 
urethrotomy  with  the  Maisonneuve,  followed  by  rapid  perineal  section, 
as  for  drainage,  or  else  he  may  open  the  perineal  urethra  first  on  a  small 
staff  and  cut  the  anterior  urethra  afterwards.  I  believe  the  former 
operation  preferable  in  most  instances. 


Fig. 


169. — Maisonnetjve 
Urethhotome. 


Fig.  170. — Oti.s  Ure- 
throtome. 


732  MEDIAN  PERINEAL  SECTION 

Passage  of  Sounds  after  Urethrotomy. — The  rule  used  to  be :  "Ee- 
tain  the  perineal  tube  four  days.  Then  pass  a  full-sized  sound.  If  chill 
follows,  replace  the  tube  for  four  days  more."  Such  a  rule  is  wrong 
in  two  essential  particulars:  the  tube  should  be  removed  on  the  first  or 
second  day,  the  first  sound  passed  between  the  tenth  and  fourteenth. 
A  single  sound  (25  F.)  will  be  found  to  pass  much  more  readily  then 
than  it  would  have  earlier. 

If  the  stricture  recontracts  tightly  before  the  tenth  day,  this  shows 
it  should  have  been  resected. 

Subsequently  sounds  are  passed  every  fourth  day;  no  more  than 
two  sounds  being  passed  on  any  one  occasion.  The  full  size  (30  F.)  is 
not  reached  until  nearly  a  month  after  operation. 


PERINEAL  SECTION  WITHOUT  A  GUIDE 

Preliminary  Sounding. — Every  eifort  should  be  made  to  insinuate 
an  instrument  through  the  stricture,  both  before  and  after  the  anesthetic 
has  been  administered. 

Injection  of  Methylene  Blue.i— An  0.5  per  cent  solution  of  methy- 
lene blue  is  injected  into  the  meatus  and  milked  along  the  urethra. 
Within  a  minute  it  will  find  its  way  through  the  tightest  stricture  into 
the  bladder,  deeply  staining  the  tissues  as  it  goes.  As  much  as  remains 
in  the  anterior  urethra  is  then  washed  away  with  sterile  water. 

The  Operation. — The  urethral  staff  is  passed  into  the  perineal  ure- 
thra. If  this  is  impossible  a  filiform  will  almost  always  pass.  (Failing 
this,  it  is  wiser  to  perform  retrograde  catheterization  than  to  attempt 
to  find  the  lumen  of  the  perineal  urethra  by  chance  dissection.)  The 
median  perineal  incision  is  then  made  a  trifle  farther  forward  than 
usual,  opening  the  urethra  freely  in  front  of  the  stricture — i.  e.,  be- 
tween it  and  the  meatus.  The  urethral  walls  are  then  pulled  apart  by 
loosely  knotted  sutures  (Fig.  168)  or  by  artery  clamps.  The  urethra 
is  thus  pulled  flush  with  the  surface  of  the  wound,  its  floor  slit  almost 
but  not  quite  to  the  orifice  of  the  stricture,  and  then,  guided  by  touch 
alone,  the  surgeon  attempts  to  introduce  a  probe  through  the  stricture. 

It  is  to  be  remembered  that  false  passages  are  likely  to  be  on  the  floor 
of  the  urethra,  and  they  deviate  from  the  median  line  if  upon  the  side 
walls.  Therefore,  the  point  of  the  probe  should  be  kept  strictly  in  the 
median  line,  and  should  be  guided  by  the  roof  of  the  urethra.  Its  gen- 
eral direction  should  be  that  of  the  long  axis  of  the  patient's  body. 

If  the  urethra  is  pulled  well  up  toward  the  surface  of  the  perineum, 
and  the  maneuver  is  carried  out  with  care,  it  almost  invariably  suc- 
ceeds.   A  perineal  section  without  a  guide  is  thus  turned  into  a  perineal 

*This  suggestion  we  owe  to  Cecil,  Joxir.  A.  M.  A.,  1913,  Ix,  1606. 


OPERATION  FOR  RUPTURE  OF  THE  URETHRA  733 

section  with  a  guide,  as  soon  as  the  probe  has  passed  into  the  stricture ; 
but,  even  though  it  passes  apparently  in  the  right  track,  one  should  not 
be  too  sure  that  it  is  not  in  a  false  passage.  The  floor  of  the  urethra 
is  carefully  divided  along  the  probe;  and,  inasmuch  as  the  tight  band 
of  the  stricture  is  usually  very  narrow,  a  slight  advance  brings  one  to  the 
dilated  portion  of  the  urethra  behind,  which  is  readily  recognizable, 
after  which  protruding  masses  of  scar  are  cut  away  and  the  operation 
completed  as  above  described. 

In  case  the  probe  does  not  pass,  two  courses  are  open  to  the  surgeon. 
The  safest  method  is  to  do  a  retrograde  catheterization ;  i.  e.,  perform 
suprapubic  section,  introduce  a  woven  catheter,  or  a  prostatic  sound  or 
catheter  with  a  long  curve,  into  the  bladder,  and  thence  into  the  urethra 
down  to  the  posterior  surface  of  the  stricture.  One  then  returns  to  the 
perineum  and  opens  the  urethra  on  the  point  of  the  sound.  ^ 

The  second  alternative  is  to  continue  in  the  perineum.  The  so-called 
Unerring  Thrust  of  Cock,  which  consists  in  plunging  the  knife  blindly 
into  the  tissues  in  the  general  direction  of  the  apex  of  the  prostate,  is  a 
hideous  mutilation  absolutely  to  be  condemned.  The  best  suggestion 
is  Young's.  Transform  the  median  incision  into  a  bilateral  one  by 
diverging  incisions  from  its  posterior  extremity;  dissect  the  perineum 
widely,  as  in  extra-urethral  prostatectomy,  and  upon  reaching  the 
apex  of  the  prostate  open  the  urethra  there. 

If  the  median  perineal  section  has  been  performed  under  cocain,  it 
is  sometimes  possible  to  persuade  the  patient  to  urinate  a  drop  or  two, 
when  close  watching  will  show  the  hole  from  which  this  drop  exudes. 


THE  OPERATION  FOR  RUPTURE  OF  THE  URETHRA 

With  the  patient  in  the  lithotomy  position  the  hematoma,  which 
fills  the  median  line  of  the  perineum,  is  incised  and  the  clots  evacuated. 
A  small  sound  is  then  inserted  into  the  urethra.  If  the  canal  has  not 
been  completely  divided  the  sound  passes  into  the  bladder,  the  rupture 
is  readily  identified,  and  the  operation  completed  like  an  ordinary  peri- 
neal section.  But  if  the  urethra  has  been  completely  divided  the  sound 
appears  in  the  perineum,  and  wide  retraction  exposes  the  end  of 
the  urethra.  The  torn  membranous  urethra  can  usually  be  readily 
found  and  a  probe  inserted  into  the  bladder  to  be  followed  by  a  perineal 
tube.  If  the  posterior  section  of  the  urethra  is  not  immediately  recog- 
nized suprapubic  section  and  retrograde  catheterization  should  be  done. 
Indeed,  there  is  a  growing  tendency  to  treat  these  cases  by  suprapubic 
rather  than, by  perineal  drainage.     Marion's  operation  is  a  type.     The 

^  Sinclair  has  devised  an  ingenious  retrograde-troear-cystoscope  guide  to  sim- 
plify this  operation   {N.  Y.  Med.  Jour.,  Apr.  4,  1914). 


734  MEDIAN  PERINEAL  SECTION 

two  ends  of  the  urethra  are  sutured  together  with  plain  catgut  while 
tension  sutures  of  chromic  catgut  take  the  strain  off  the  actual  line  of 
union  of  the  mucosa.  The  superficial  tissues  of  the  perineum  are 
closed  over  a  good-sized  cigarette  drain  down  to  the  line  of  suture  in  the 
urethra.  A  suprapubic  tube  takes  care  of  the  drainage  for  at  least 
ten  days  after  operation. 


RESECTION  OF  THE  URETHRA  (CABOT'S  METHOD) 

Cabot's  method  of  urethral  resection  for  stricture  is  the  following: 
The  urethra  is  disclosed  through  a  median  perineal  incision  and 
the  bulbocavernosus  muscle  divided  longitudinally  for  a  distance  of 
about  three  centimeters  with  the  tightest  point  at  its  center  (as  indicated 
by  the  distance  a  sound  will  go  in  the  urethra).  The  bulb  which  is 
thus  laid  bare  is  dissected  free  from  the  corpora  cavernosa,  from  the 
triangTilar  ligament  forward  for  two  or  three  centimeters.  It  is  then 
opened  in  the  usual  manner  and  the  stricture  carefully  divided.  With 
a  22  F.  sound  in  the  urethra  the  mucous  membrane  and  overlying 
spongy  body  are  then  reunited  by  catgTit  sutures  which  close  the 
longitudinal  wound  transversely  thus  puckering  up  the  urethra  longi- 
tudinally and  enlarging  the  stricture.  A  puncture  is  then  made  in  the 
bulb  or  membranous  urethra  posterior  to  this  line  of  suture  and  a  16  F. 
soft-rubber  catheter  inserted  into  the  bladder  for  drainage  (suprapubic 
drainage  is  sometimes  preferable  to  this).  Cabot  advises  daily  in- 
jection of  argyrol  into  the  anterior  urethra.  I  believe  it  preferable  to 
inject  nothing.  The  perineum  is,  of  course,  left  open  and  heals  by 
granulation.  The  first  sound  is  passed  at  the  end  of  two  weeks.  The 
urethra  may  be  found  relatively  distorted  and  pocketed,  but  the  sound 
will  readily  pass  if  intelligently  used.  Cases  operated  upon  by  this 
method  certainly  seem  to  reeontract  much  less  rapidly  than  do  those 
that  are  simply  incised. 


OPERATIVE  TREATMENT   OF  PERI-URETHRITIS 

The  principles  of  the  treatment  of  peri-urethritis  are  the  same 
whether  the  infection  be  nothing  more  than  a  small  circumscribed  ab- 
scess or  whether  it  extends  as  a  stinking  gangrene  throughout  the  peri- 
neum, the  scrotum,  the  pubes,  and  the  buttocks.  There  is  only  one 
exception:  the  strictly  localized  abscess  may  be  incised  without  opening 
the  urethra.  But  this  usually  results  in  a  fistula  which  does  not  heal 
until  the  urethra  is  actually  open  (the  rule  here  being  thus  practically 
the  same  as  that  for  the  treatment  of  perirectal  suppuration). 


OPERATIVE  TREATMENT  OF  PERI-URETHRITIS  735 

For  all  other  conditions  the  following  rules  apply : 

1.  The  first  incision  should  be  in  the  median  line  of  the  perineum 
extending  from  one  end  to  the  other  of  the  infected  or  sloughing  mass. 
If  the  scrotum  is  involved  this  is  split.  The  urethra  is  thus  laid  bare  on 
a  sound  or  filiform  (methylene  blue  is  very  useful  in  the  discovery  of 
the  urethra  in  certain  suppurating  cases,  but  phlegmonous  infections 
usually  occur  about  canals  that  are  not  very  tightly  strictured).  The 
urethra  is  opened  at  that  point  at  which  it  is  most  nearly  approached 
by  the  infection.  If  this  is  not  in  the  posterior  portion  of  the  bulb, 
a  second  incision  had  better  be  made  there  and  the  perineal  tube  in- 
serted in  the  usual  spot. 

2.  From  this  central  incision  radiating  cuts  in  various  directions 
are  made  over  the  buttocks,  into  the  groin  and  through  the  scrotum  and 
perineum,  so  as  to  open  every  pocket  widely.  Any  pockets  that  are  not 
freely  opened  will  require  a  secondary  operation. 

3.  If  the  cavity  is  a  suppurating  one  its  granulating  wall  is  well 
curetted.  If  it  is  a  phlegmonous  one,  as  much  as  possible  of  the 
sloughing  tissue  is  cut  away. 

The  healing  of  such  a  wound  is,  of  course,  a  tedious  matter  and  a 
secondary  operation  may  be  required  to  close  the  urethral  fistula. 


CHAPTER   LXXV 

OPERATIONS  UPON  THE  PROSTATE  AND  SEMINAL  VESICLES 

Fob  several  years  past  I  have  performed  no  type  of  prostatectomy 
excepting  the  suprapubic,  yet  one  cannot  overlook  the  brilliant  results 
of  Young  with  his  perineal  operation.  It  is  questionable  whether  the 
intra-urethral  method  of  prostatectomy  still  holds  a  place  in  the  mod- 
ern surgeon's  armamentarium.  It  is  certainly  possible  to  remove  small 
intra-urethral  prostatic  lobes  very  satisfactorily  by  this  method,  and 
therefore  we  include  it. 

SUPRAPUBIC  PROSTATECTOMY 

The  operation  of  suprapubic  prostatectomy  was  first  performed  by 
McGill.  Its  technic  was  further  developed  by  my  father,  by  Fuller,  by 
Freyer,  and  by  Squier.  The  operation,  as  described  below,  is  shorn 
of  many  of  the  complexities  favored  by  certain  operators.  It  is  our  im- 
pression that  the  more  simply  and  directly  the  operation  is  performed 
the  more  rapidly  and  certainly  does  the  patient  get  well. 

Preparation  of  the  Patient. — The  patient  with  a  compensating  blad- 
der, in  catheter  life,  comfortably  infected,  without  any  acute  or  chronic 
complications,  and  a  satisfactory  phenolsulphonephthalein  output  may 
be  operated  upon  safely  with  scarcely  any  preliminary  treatment.  But 
such  patients  are  rare.  The  preliminary  treatment  is  chiefly  con- 
cerned with  accustoming  the  urinary  organs  to  catheter  drainage  with 
its  accompanying  infection.  It  is  described  on  page  669.  It  usually 
lasts  from  one  to  six  weeks. 

I  have  kept  patients  under  observation  for  three  months  before  suc- 
cessfully operating  upon  them. 

Anesthesia. — The  Mayos  use  ether;  Young,  Cabot,  Squier  and 
Lower  prefer  gas  and  oxygen,  though  the  last  has  also  used  local  anes- 
thesia. Chute  employs  spinal  anesthesia.  My  own  present  prefer- 
ence, especially  for  rather  desperate  cases,  is  to  begin  the  operation  with 
local  anesthesia,  continuing  this  until  the  bladder  wall  is  reached  and 
suspended  with  the  skin  hooks.  Then  the  patient  is  given  gas  and 
oxygen,  the  bladder  rapidly  incised  and  the  prostate  removed.  The 
general  anesthetic  is  then  stopped  and,  although  the  patient  is  awake 

736 


SUPRAPUBIC  PROSTATECTOMY  737 

almost  immediately,  the  local  anesthesia  of  the  abdominal  wall  gives  one 
plenty  of  time  to  suture  the  wound  neatly. 

The  Incision — The  belly  wall  and  bladder  are  opened  in  the  usual 
manner.  The  incision  in  the  belly  wall  should  almost  reach  the  um- 
bilicus if  the  patient  is  fat.  But  for  relatively  lean  patients  a  much 
shorter  incision  suffices.  The  incision  in  the  bladder  wall  must  be  long 
enough  to  admit  two  fingers. 

The  Prostatectomy. — The  operation  can  be  performed  more  rapidly 
with  the  bare  hand  though  I  have  removed  many  prostates  with  the 
gloved  hand.  Two  fingers  are  introduced  into  the  bladder  and  two 
fingers  of  the  opposite  hand  into  the  rectum  (some  operators  prefer  to 
introduce  the  whole  hand  through  the  belly  wall  and  not  to  use  rectal 
counterpressure).  One  should  never  try  to  do  a  prostatectomy  with 
only  one  finger  in  the  bladder,  or  only  one  finger  in  the  rectum;  two 
are  required,  in  the  one  case  to  grasp,  in  the  other  to  balance,  the 
prostate. 

With  the  index  finger  inside  the  bladder  one  searches  for  the  ure- 
thral orifice,  enters  this  and  pulls  it  quite  sharply  upward.  As  a  result 
the  mucous  membrane  tears  over  the  top  of  one  or  other  of  the  lateral 
lobes.  A  finger  is  then  inserted  in  this  tear  to  the  outer  side  of  the 
lobe.  If  there  is  no  carcinoma  the  lobe  is  freed  very  readily  from 
the  tissues  above,  to  the  outer  side,  and  below  it.  The  fingers  may  thus 
be  carried  around,  tearing  the  bladder  neck  as  they  go,  until  the  top  of 
the  opposite  lobe  is  reached.  Or  if  the  septa  between  the  lobes  are  quite 
dense  one  lobe  may  be  removed  at  a  time  and  the  other  attacked  from 
above  downward  as  the  first  one  was.  The  bladder  neck  tears  very 
readily  and  the  only  point  of  attachment  that  separates  with  difiiculty  is 
the  mucosa  at  the  region  of  the  verumontanum.  (This  tears  away  just 
behind  the.verumontanvim.)  Counterpressure  with  the  two  fingers  in 
the  rectum  materially  assists  the  manipulation.  After  all  large  lobes 
have  been  removed  one  feels  carefully  for  smaller  lobes  which  might, 
in  the  course  of  healing,  obstruct  the  urethra. 

If  the  prostate  is  small  and  sclerotic  one's  first  impression  may  be 
that  there  are  no  outstanding  lobes,  and  that  all  the  patient  requires  is  a 
division  of  his  bladder  neck.  But  careful  palpation  will  reveal,  even 
in  these  cases,  small  lobes  within  the  urethra  which  must  be  dealt  with 
in  the  manner  described  above,  each  being  removed  separately.  These 
small  lobes  are  often  very  adherent.  If  the  bladder  neck  still  appears 
to  be  somewhat  tight  after  this  procedure  it  may  be  divided  in  the 
middle  line. 

The  result  of  this  tearing  is  a  profuse  hemorrhage.  Many  devices 
have  been  suggested  to  control  this ;  my  father  devised  one,  which  he 
employed  only  a  short  time,  and  1  can  plead  guilty  of  the  same  crime. 
Three  methods  of  controlling  hemorrhage  find  favor  at  the  present  time. 


738  PROSTATE  AND  SEMINAL  VESICLES 

One  is  the  Hagner  bag/  This  is  an  oval  bag  attached  to  a  long  tube, 
not  nnlike  the  Barnes'  bag  of  the  obstetrician.  It  is  introduced  by 
forcing  the  end  of  the  tube  over  the  tip  of  a  Benique  sound  introduced 
into  the  urethra  and  projected  out  of  the  suprapubic  wound.  Before 
introducing  the  bag  a  silk  thread  is  tied  to  a  loop  upon  it  for  the  purpose 
of  extracting  it  through  the  bladder.  The  sound  is  withdrav^n,  leaving 
the  bag  inside  the  bladder.  The  bag  is  then  blown  up  with  air  until  it 
is  felt  to  be  comfortably  distended,  and  then  by  traction  upon  the  tube 
the  bag  is  drawn  snugly  into  the  cavity  left  by  removal  of  the  prostate. 
The  tube  is  then  clamped  at  the  urethral  meatus  in  such  a  way  that  a 
little  strip  of  gauze  between  it  and  the  meatus  suffices  to  protect  the 
latter,  and  the  bag  is  held  snugly  in  position.  At  the  end  of  twenty- 
four  hours  the  clamp  is  loosened  and  at  the  end  of  forty-eight  hours 
the  bag  is  removed  through  the  suprapubic  wound  by  traction  on 
the  string. 

Lower  and  others  control  hemorrhage  by  packing.  The  packing  is 
inserted,  not  only  into  the  prostatic  cavity,  but  also  against  the  adjacent 
bladder  neck,  pushing  this  inward  into  the  cavity  as  far  as  possible. 

Cabot  at  one  time  carefully  sutured  the  bladder  neck,  thereby  in- 
creasing his  mortality.  Judd  has  revived  and  modernized  the  Fenwick 
method  of  clamping  the  bleeding  points  in  the  bladder  neck.  But  the 
lengthened  anesthesia  probably  increases  the  mortality  more  than  the 
control  of  bleeding  lessens  it. 

Squier  uses  no  packing.  I  have  very  rarely  used  it,  and  have  only 
used  the  Hagner  bag  a  few  times.  In  the  gTeat  majority  of  cases  the 
furious  initial  hemorrhage  very  rapidly  diminishes  and  in  several 
instances  I  am  sure  that  the  patient  has  bled  more  and  suffered  much, 
more  on  account  of  the  presence  of  packing  or  the  Hagner  bag  in  his 
bladder  than  he  would  have  done  had  this  not  been  in  place.  But  if 
hemorrhage  needs  to  be  checked  the  Hagner  bag  is  the  best  instrument 
with  which  to  do  it.  J\Iy  own  practice  is  to  make  compression  with  a 
large  pad  against  the  bladder  neck,  forcing  this  into  the  cavity  left  by 
the  prostate  for  the  few  moments  required  to  get  the  suprapubic  tube 
ready,  and  while  the  sutures  are  being  placed  in  the  bladder.  On 
removal  of  this  pad  of  gauze  the  hemorrhage  is  usually  not  very  severe. 

Closure  of  Wound. — If  the  bladder  has  been  much  torn  a  suture  or 
two  is  taken  at  the  lower  end  of  the  incision  so  as  to  close  it  snugly 
about  the  suprapubic  tube.  Tubes  of  various  dimensions  are  used;  I 
confess  to  a  preference  for  the  large  Freyer  tube  with  lumen  almost 
large  enough  to  admit  the  little  finger.  This  tube  permits  ready  exit 
to  clots  and  also  permits  one  to  introduce  forceps  into  the  bladder  for' 
the  removal  of  clots  in  case  these  accumulate  too  rapidly  to  flow  out 
readily.     The  bhidder  is  attached  to  the  recti  muscles  and  the  belly 

^  Surg.,  Gyn.  tj'-  Obstet.,  1914,  Ixiii.  677. 


EXTRA-URETHRAL  PERINEAL  PROSTATECTOMY  739 

wall  closed  as  usual  with  a  cigarette  drain  in  the  space  of  Retzins.  If 
one  wishes  to  use  an  indwelling  catheter  from  the  beginning  this  should 
be  left  in  place  at  the  time  of  operation,  for  it  is  very  difficult  to  intro- 
duce a  catheter  through  the  torn  bladder  neck  until  several  days  after 
operation.     Continuous  irrigation  should  not  be  employed. 

After-treatment. — The  large  tube  is  left  in  place  until  the  subse- 
quent hemorrhage  stops  and  is  then  replaced  by  the  aspiration  apparatus 
above  described  on  page  718,  and  this  in  turn  replaced  by  the  indwelling 
urethral  catheter  at  the  end  of  the  second  or  third  week. 


EXTRA-URETHRAL  PERINEAL  PROSTATECTOMY 

The  modern  operation  of  extra-urethral  perineal  prostatectomy  was 
devised  by  Proust.  The  technic  of  Young  is  preferable  to  that  of 
Proust,  inasmuch  as  Young  attacks  the  prostate  through  two  incisions 
— one  for  each  lateral  lobe — whereas  Proust  splits  the  prostate  in  the 
median  line,  thereby  destroying  the  vasa  deferentia  and  getting  at  the 
lateral  lobes  only  indirectly. 

Although  Young  uses  this  operation  upon  all  cases,  it  is  certainly 
not  the  operation  of  choice  for  the  average  surgeon — even  the  average 
specialist.  The  prostate  obstructs  the  urethra  at  the  bladder  neck. 
Prostatectomy  by  the  suprapubic  route  inevitably  at  least  recognizes 
and  mutilates  this  obstacle,  while  much  prostatic  tissue  is  often  re- 
moved through  the  perineum  by  unskilled  operators  who  do  not  even 
reach  the  obstruction.  Moreover  the  complications  of  badly  performed 
perineal  prostatectomy  are  much  graver  than  those  of  the  suprapubic 
operation. 

Position  of  the  Patient — The  patient  is  put  in  the  so-called  "exag- 
gerated lithotomy  position,"  the  buttocks  elevated  by  tilting  up  a  flap 
at  the  foot  of  the  operating  table  until  the  perineum  is  practically  a 
horizontal  plane — the  legs  being  so  fixed  by  lithotomy  supports  that 
both  hips  and  knees  are  forcibly  flexed. 

Special  Instruments  Required — The  special  instruments  required 
for  Young's  operation  are  his  four  retractors,  forceps  for  clamping  the 
prostatic  lobes,  enucleator,  and  vesical  tractor,  also  a  sound,  a  staff,  and 
a  sharp-pointed  bistoury. 

Sound. — A  sound  is  introduced  into  the  urethra  as  a  giiide. 

Incision — The  operation  may  be  perfonned  through  a  curved  pre- 
rectal  section  running  from  one  ischial  tuberosity  to  the  other,  and  pass- 
ing about  3  cm.  in  front  of  the  anus  (Proust)  ;  or  one  may  make  two 
lateral  converging  incisions  and  connect  them  in  front  by  a  snip  of  the 
scissors  (Young). 

After  incision  of  the  skin  and  fascia  the  flap  is  drawn  back  and  a 


740 


PROSTATE  AND  SEMINAL  VESICLES 


finger  pushed  into  the  loose  cellular  tissue  on  either  side  of  the  perineal 
body.  The  bulb  of  the  urethra,  surrounded  by  its  muscles,  is  thus  fully 
exposed  and  the  perineal  body  divided  with  scissors  immediately  be- 
neath it.  Young  s  bifid  retractor  is  then  introduced  posteriorly  and 
strong  traction  made  while  the  bulb  of  the  urethra  is  held  up  and 
carefully  dissected  free. 

It  is  most  important  in  this,  and  the  succeeding  steps  of  the  opera- 
tion, to  stick  close  to  the  urethra,  feeling  one's  way  on  the  sound  in  that 
canal.  As  soon  as  the  most  dependent  portion  of  the  bulb  has  been 
freed  (it  is  identified  by  its  median  raphe),  the  line  of  incision  turns 
at  a  right  angle  to  strike  for  the  membranous  urethra.     Otherwise  the 

rectum  is  opened  right 
here.  As  soon  as  the 
bulb  has  been  freed  and 
drawn  well  forward, 
exposing  the  beginning 
of  the  membranous 
urethra,  blunt  dissec- 
tion is  made  on  either 
side  to  free  the  cellular 
tissue,  and  the  loose 
muscular  bag  of  rectum 
is  felt  adherent  to  the 
membranous  urethra.  A 
small  band  of  muscle  fi- 
bers runs  from  the  rec- 
tum to  the  membranous 
urethra,  and  this  mus- 
cular band,  the  recto- 
urethralis  muscle,  is  divided  with  great  care  very  close  to  the  mem- 
branous urethra. 

If  the  surgeon  is  in  doubt  as  to  his  bearings  at  this  point  of  the 
operation,  he  should  insert  a  finger  into  the  rectum  in  order  to  feel  his 
way  most  carefully,  for  the  bowel  lies  right  against  the  urethra  and 
may  easily  be  opened.  As  soon  as  the  recto-urethralis  is  cut,  the  finger 
may  be  swept  across  the  front  of  the  rectum,  and  this  pushed  back  safely 
out  of  the  way. 

Blunt  dissection  discloses  the  prostate.  The  bifid  retractor  is  now 
exchanged  for  the  broad  posterior  retractor,  and  two  lateral,  narrow 
retractors  are  inserted.  Then  the  blunt  dissection  is  carried  upward 
along  the  posterior  surface  of  the  prostate,  carefully  following  the  lines 
of  this  organ  and  pushing  back  the  rectum  until  the  whole  of  the  pos- 
terior surface  of  the  prostate  has  been  freed  from  adhesions  and  stands 
out  plainly  in  the  wound.     It  will  then  be  seen  that  there  is  a  space 


Fig.  171. — Perineal  Incisions.  A,  C,  median  incision; 
D  B  E  Young's  incision;  D  E  (curve),  Proust's  inci- 
sion; F  D  E,  incision  for  vesiculotomy. 


EXTRA-URETHRAL  PERINEAL  PROSTATECTOMY  741 

about  1  cm.  in  length  lying  between  the  bulb  in  front  and  the  apex  of  the 
prostate  behind.     The  membranous  urethra  is  opened  at  this  point. 

In  opening  the  urethra  by  a  stroke  of  the  knife,  the  unfamiliar  sur- 
geon may  find  it  difficult  to  cut  through  the  mucous  membrane.  He 
may  be  lost  in  the  tissues  of  the  canal,  and  had,  therefore,  before  per- 
forming this  step,  better  remove  the  sound  and  replace  it  by  a  grooved 
staff,  upon  which  incision  is  more  readily  made.  The  finger  is  then 
introduced  into  the  membranous  urethra  and  thence  into  the  prostatic 
urethra,  and  the  urethral  surface  of  the  gland  and  the  bladder  neck 
carefully  palpated  as  in  intra-urethral  prostatectomy. 

The  vesical  tractor  is  now  introduced  through  this  incision  into  the 
urethra  and  thence  into  the  bladder,  opened,  and  drawn  upward  and 
forward  so  as  to  make  strong  traction  upon  the  lateral  lobes  of  the 
gland. 

According  to  Albarran's  technic,  the  finger  is  introduced  and  trac- 
tion made  with  this. 

The  surgeon  now  plunges  a  sharp-pointed  bistoury  about  2  cm.  deep 
into  one  lateral  lobe  near  its  apex  and  about  1  cm.  from  the  median  line. 
The  knife-blade  should  penetrate  the  prostatic  tissue  close  to  the  urethra, 
separating  the  lobe  partly  from  that  canal.  The  knife  is  then  with- 
drawn with  a  sweep,  dividing  the  ''capsule"  of  the  gland  longitudinally 
for  about  2  cm.  This  "capsule"  is  fully  1  cm.  thick,  composed  chiefly 
of  posterior  lobe,  partly  of  compressed  lateral  lobe  tissue. 

The  outer  surface  of  the  lobe  is  then  freed  either  by  the  enucleator 
of  Young  or  by  the  finger;  and  this  enucleation  is  carefully  carried 
well  up  under  the  bladder  neck  in  order  to  enucleate  a  part,  at  least, 
of  the  median  bar  or  lobe.  The  loosened  gland  tissue  is  then  seized 
with  the  specially  devised  forceps  and  drawn  downward,  while  its  outer 
surface  is  fully  freed. 

The  inner  surface  of  the  hypertrophied  lobe  adheres  strongly  to  the 
posterior  urethra.  If  the  original  incision  with  the  knife  has  been  deep 
enough,  and  has  reached  close  beneath  the  urethral  capsule  of  the  gland, 
these  adhesions  have  been  in  large  measure  freed  by  this  incision ;  but  a 
certain  amount  of  freeing  still  remains  to  be  done  with  scissors,  and 
this,  if  done  carelessly,  usually  results  in  rupture  of  the  mucous  mem- 
brane of  the  prostatic  urethra. 

Having  removed  a  single  lateral  lobe  in  this  way,  its  fellow  is  re- 
moved through  a  similar  incision  in  the  opposite  side. 

After  the  lateral  lobes  have  been  removed  the  tractor  is  removed 
and  the  finger  introduced  into  the  urethra  and  through  the  bladder  neck, 
which  is  forcibly  drawn  downward.  A  finger  is  then  introduced  into 
one  of  the  prostatic  incisions,  and  the  region  of  the  bladder  neck  care- 
fully palpated  for  further  masses  of  hypertrophied  gland  tissue.  These, 
if  found,  are  carefully  removed. 


742  PROSTATE  AND  SEMINAL  VESICLES 

Young  removes  middle  lobes  through  one  of  the  lateral  incisions  by 
turning  his  tractor  downward  and  pressing  upon  them ;  but  other  sur- 
geons succeed  better  by  employing  the  finger  as  a  tractor.  Pedunculated 
lobes  should  be  removed  through  the  urethra. 

At  the  end  of  the  operation  a  double-current  tube  is  placed  in  the 
bladder  through  the  wound  in  the  membranous  urethra,  which  may  be 
closely  sutured  around  it,  if  it  has  been  unduly  enlarged.  The  incisions 
of  the  prostate  are  carefully  packed  in  order  to  prevent  bleeding;  but 
no  extraprostatic  packing  is  required. 

In  order  to  prevent  subsequent  sloughing  of  the  rectum,  the  edges 
of  the  levator  ani  muscle  are  caught  together  by  a  strong  catgut  suture. 
This  throws  the  rectum  well  back  out  of  the  wound.  The  lateral  parts 
of  the  external  incision  are  then  closed  up  to  the  central  point,  whence 
the  perineal  tube  and  gauze  issue. 

Difficulties  of  the  Operation — A  fibrous  lobe  is  very  difficult  to 
remove  without  tearing  the  prostate  all  to  pieces,  and  an  obstruction  due 
to  median  bar  should  certainly  not  be  attacked  by  this  method.  Pedun- 
culated median  lobes  cannot  be  conveniently  gotten  out  through  this 
incision. 

Injury  to  the  rectum  may  occur  at  the  time  of  the  operation.  I  tore 
the  rectum  in  the  first  three  cases  in  which  I  operated  by  this  method. 
The  wound  should  be  promptly  sutured,  and  special  care  should  be  taken 
to  bring  together  the  levator  ani  muscles  in  front  of  the  bowel.  In  my 
three  cases  the  wound  in  the  bowel  healed  kindly,  but  others  have  not 
been  so  fortunate.  Young  states  that  if  the  bowel  is  opened  one  should 
abandon  the  perineal  for  the  suprapubic  route. 

After-treatment. — Continuous  irrigation  is  maintained  through  the 
double  current  tube  for  about  six  hours ;  the  gauze  drains  are  removed 
at  the  end  of  eighteen  hours ;  the  perineal  tube  at  the  end  of  twenty- 
four  or  forty-eight  hours ;  and  the  patient  is  then  promptly  gotten  out 
of  bed  if  that  is  possible. 

Postoperative  Complications. — The  special  postoperative  complica- 
tions are  hemorrhage,  rectal  fistula  and  incontinence  of  urine. 

Intravesical  hemorrhage  does  not  occur  if  the  operation  has  been 
properly  performed,  but  several  deaths  have  occurred  from  hemorrhage 
into  the  wound.  This  is  likely  to  occur  only  in  old,  septic  individuals, 
for  whom  extra-urethral  prostatectomy  is  not  peculiarly  suited,  except 
at  the  hands  of  an  expert. 

It  is  stated  that  the  bowel  may  slough  after  operation,  or  that  the 
rectal  tube  may  be  forced  through  it.  I  question  the  probability  of 
either  accident  unless  the  bowel  was  injured  at  the  time  of  operation. 

The  postoperative  treatment  of  urethrorectal  fistula  consists  in 
keeping  a  small  catheter  in  the  perineal  wound  in  the  bladder  for  about 
a  week  and  at  the  same  time  keeping  the  bowel  as  clean  as  possible  by 


INTRA-URETHRAL  PERINEAL  PROSTATECTOMY  743 

daily  irrigations  with  saline  solution.  At  the  end  of  a  week  the  small 
catheter  in  the  perineal  wound  is  replaced  by  an  indwelling  urethral 
catheter  while  rubber  tissue  drains  are  so  applied  in  the  perineal  wound 
as  to  prevent  pocketing  and  encourage  the  earliest  possible  healing. 
Under  these  circumstances  the  wound  often  heals  perfectly.  If  it  does 
not,  a  subsequent  operation  for  urethroperineal  or  rectoperineal  or 
urethrorectoperineal  fistula  may  be  required  (p.  764). 

Incontinence  of  urine  follows  prostatectomy  only  when  the  external 
sphincter  has  been  injured.  It  does  not  occur  after  a  properly  per- 
formed prostatectomy  of  this  type  though  it  is  not  uncommon  after 
intra-urethral  perineal  prostatectomy. 


INTRA-URETHRAL  PERINEAL  PROSTATECTOMY 

Ten  years  ago  this  operation  threatened  for  a  time  to  become  the 
operation  of  choice  for  prostatectomy.  But  even  its  ablest  exponents 
find  it  a  dangerous  procedure  (hemorrhage,  incontinence)  for  the  re- 
moval of  large  or  intravesical  growths.  For  the  removal  of  small 
intra-urethral  adenomata  it  is  an  admirable  procedure. 

Incision — A  rather  long  median  perineal  incision  is  made  upon  the 
urethral  staff.  If  palpation  has  shown  that  the  perineum  is  not  very 
deep,  I  prefer  to  open  the  bulbous  urethra  as  in  external  urethrotomy; 
but  the  custom  of  most  surgeons  is  to  separate  the  bulb  by  section  of 
the  median  perineal  body  and  to  draw  it  forward,  bringing  the  mem- 
branous urethra  into  view.  The  urethra  is  then  opened  at  this  point, 
dividing  practically  the  whole  of  the  membranous  urethra  in  the  median 
line  behind.     The  staff  is  then  withdrawn  and  the  finger  introduced. 

Examination  of  the  Prostate — The  finger  then  enters  the  prostatic 
urethra  and  estimates  the  nature  of  the  obstruction  at  the  neck  of  the 
bladder,  verifying  the  accuracy  of  the  preliminary  cystoscopy.  In 
order  to  do  this  properly,  the  finger  must  be  introduced  into  the  blad- 
der and  swept  around  the  bladder  neck  on  all  sides — a  maneuver  which 
is  very  difficult  if  the  perineum  is  deep,  and  which  tears  the  bladder 
neck  if  this  is  strictured ;  it  is  made  easier  by  counterpressure  on  the 
hypogastrium.  The  finger  is  then  withdrawn  and  palpation  of  the 
lateral  lobes  made  upon  a  finger  in  the  rectum.  In  no  other  way  can 
their  size  and  shape  be  correctly  estimated. 

Removal  of  the  Obstruction.— If  enlarged  lateral  lobes  are  felt, 
these  are  removed  as  follows: 

A  curved,  sharp-pointed  bistoury  is  introduced  into  the  prostatic 
urethra  on  the  finger  until  its  point  is  opposite  the  most  bulging  portion, 
of  the  lateral  lobe.  It  is  then  plunged  into  that  lobe  to  a  depth  of  at 
least  1  cm.  and  drawn  out,  making  a  deep,  longitudinal  incision  in  the 


744  PROSTATE  AND  SEMINAL  VESICLES 

lateral  wall  of  the  urethra.  The  knife  is  then  withdrawn  and  th«  finger 
reintroduced.  If  the  incision  has  been  deep  enough,  the  finger  feels 
the  lobulated  tissue  of  the  hypertrophied  gland  and  proceeds  to  remove 
this  in  the  following  manner: 

The  finger  is  first  worked  outward  between  the  hypertrophied  tissue 
and  the  so-called  capsule,  its  movement  being  directed  by  the  sensation 
of  lobulated  tissue  on  one  side  and  smooth  capsule  on  the  other.  The 
lobe  usually  separates  very  readily  on  the  outer  side  and  the  finger  is 
rapidly  swept  up  and  down  until  the  lobe  is  quite  free  on  its  outer 
aspect.  A  sponge-forceps  is  then  inserted,  and  the  lobe  grasped  and 
pulled  down  gently  (too  great  traction  only  tears  the  tissue),  while 
the  finger  reaches  farther  and  farther  upward,  dissecting  around  the 
upper  end  of  the  lobe.  Finally,  the  whole  lobe  is  freed  except  that  part 
of  it  adherent  to  the  mucous  membrane.  This  is  freed  as  much  as 
possible,  but  pieces  of  it  usually  adhere  to  the  lobe  when  it  is  finally 
removed  by  the  forceps. 

The  same  maneuver  is  then  performed  on  the  opposite  side. 

If  there  is  general  enlargement  of  the  gland,  the  dissection  of  the 
outer  aspect  of  one  lobe  naturally  carries  the  finger  underneath  the 
median  bar  and  over  to  the  other  side  of  the  urethra.  The  whole  pros- 
tate should  not  be  removed  in  one  piece,  for  overstretching  of  the  mem- 
branous urethra  is  carefully  to  be  avoided.  Pedunculated  median  lobes 
may  be  caught  in  the  volsella  and  removed  by  snipping  the  mucous 
membrane  at  their  base  with  long  scissors. 

The  operation  is  closed  by  the  introduction  of  a  double-current 
drainage-tube.  Gauze  packing  to  control  hemorrhage  is  not  required 
if  the  operation  is  confined  to  the  removal  of  small  adenomata. 

Difficulties  in  the  Operation — Difficulties-  in  enucleation  of  the 
hypertrophied  tissue  may  usually  be  overcome  by  firmly  grasping  the 
lobes  in  the  volsellum.  In  some  cases  deep  hypogastric  pressure  is  of 
great  assistance,  or  a  finger  in  the  rectum  may  help ;  but  if  the  perineum 
is  very  deep  and  the  projection  of  the  prostate  largely  intravesical,  the 
Syms  bag  is  a  great  help  in  drawing  down  the  gland.  This  bag  should 
be  filled  with  water,  not  with  air.  Its  tube  is  then  clamped  and  drawn 
upon  firmly  during  the  operation  as  a  retractor. 

If  the  lobes  under  process  of  enucleation  are  not  tightly  grasped  by 
the  forceps,  they  may  slip  into  the  bladder  unless  the  Syms  bag  is  used. 
They  are  best  removed  by  a  lithotomy  forceps. 

Careful  operation  will  always  avoid  the  one  grave  difficulty  of  the 
procedure,  viz.,  tearing  into  or  through  the  capsule  of  the  hypertrophied 
lobe.  If  this  accident  should  occur,  it  is  recognized  by  the  fact  that  the 
finger  passes  into  a  space  on  all  sides  of  which  the  tissues  are  smooth, 
and  in  which  none  of  the  lobulated,  hypertrophied  gland  can  be  felt. 
Such  a  tear  should  be  closely  packed  with  gauze,  in  order  to  avert 


OPERATIONS  OTHER  THAN  PROSTATECTOMY  745 

hemorrhage;  otherwise,  no  gauze  packing  is  required.  Tearing  of  the 
bladder  neck  should  be  avoided  as  far  as  possible,  though  some  tearing 
of  this  part  of  the  urethra  is  usually  unavoidable. 

Postoperative  Care — Continuous  irrigation  must  be  begun  immedi- 
ately— before  the  patient  leaves  the  operating  table ;  otherwise  clots 
may  accumulate  before  the  patient  gets  into  his  bed,  which  cannot  be 
removed  without  great  difficulty,  and  may  require  suprapubic  section. 
Irrigation  is  kept  up  until  the  fluid  no  longer  returns  bloody,  and  for 
at  least  six  hours  after  operation. 

It  is  usually  better  to  remove  the  perineal  tube  within  two  days 
after  operation,  though  if  there  is  very  marked  cystitis  and  the  patient's 
condition  is  good,  the  tube  may  be  kept  in  a  longer  time;  but  it  is  of 
the  greatest  importance  to  get  the  patient  out  of  bed  as  soon  as  possible. 

It  is  well  to  pass  a  single,  full-sized  sound  into  the  urethra  at  the 
end  of  the  first  or  second  week  after  operation,  to  be  sure  that  no  tend- 
ency to  stricture  formation  is  occurring  during  the  healing,  although 
stricture  is  a  very  unusual  complication  of  the  convalescence.  Watson 
states  that  he  knows  of  only  6  cases  of  stricture  of  the  prostatic  urethra 
following  this  method  of  perineal  prostatectomy. 

Postoperative  Complications — The  immediate  postoperative  com- 
plications of  hemorrhage  and  urinary  septicemia  should  be  dealt  with 
according  to  the  rules  laid  down  above  and  in  Chapter  LXIX. 

The  complications  especially  to  be  feared  after  this  operation  are 
epididymitis,  impotence^  incontinence  of  urine,  and  persistence  of  reten- 
tion.    The  first  two  may  follow  any  form  of  prostatectomy. 

Ueinaey  Incontinence. — A  minor  degree  of  incontinence  of  urine 
— i.  e.,  a  lack  of  tightness  in  urination,  whereby  the  patient  may  lose 
from  a  few  drops  to  a  teaspoonful  or  so  every  day — is  a  complication  of 
moderate  frequency  after  this  form  of  prostatectomy.  It  is  due  to  the 
cutting  and  stretching  of  the  membranous  urethra. 

Total  incontinence  ensues  when  the  internal  sphincter  has  been 
badly  torn. 

Eetention  of  Urine. — Failure  to  relieve  the  prostatic  obstacle  is 
due  to  overlooking  a  bar  or  lobe  at  the  bladder  neck. 


OPERATIONS  OTHER  THAN  PROSTATECTOMY  FOR  THE 
RELIEF  OF  OBSTRUCTION  AT  THE  BLADDER  NECK 

For  reasons  already  given,  I  believe  prostatectomy  preferable  to 
any  other  operation  for  prostatism  in  any  of  its  forms  even  when  the 
contraction  of  the  bladder  neck  by  sclerosis  seems  to  be  the  chief  lesion, 
and  the  enlargement  of  the  lateral  lobe  relatively  insignificant. 

But  even  with  this  restriction  there  are  cases,  notably  of  stricture 


ue. 


PROSTATE  AND  SEMINAL  VESICLES 


at  the  bladder  neck  after  prostatectomy,  not  amenable  to  prostatectomy. 
Such  a  scar  may  be  relieved  by  a  deep  incision  of  the  bladder  neck  made 
through  a  suprapubic  or  a  perineal  opening.  In  order  to  avoid  the 
very  annoying  hemorrhage  that  results  from  so  deep  a  cut  various  opera- 
tions have  been  proposed.  I  give  them  in  the  order  of  my  personal 
preference,  omitting  the  Bottini  operation  since 
that  has  fallen  into  general  disfavor : 

Galvanocauterization   of   the   prostate    (Chet- 
wood). 

The  prostatic  punch  (Young). 
The  D'Arsonval  current  (Bugbee). 


GALVANOCAUTERIZATION  OF  THE  PROSTATE 

Incision  in  the  bladder  neck  by  cautery  has  the 
double  advantage  of  not  bleeding  and  of  healing  so 
slowly  that  the  burned  groove  leaves  practically 
the  same  opening  in  the  bladder  neck  as  is  felt  at 
the  time  of  operation.  The  neck  of  the  bladder 
should  be  cauterized  after  perineal  incision  and 
palpation  of  the  obstruction  according  to  Chet- 
wood's  technic. 

The  blind  Bottini  operation  should  never  be 
performed. 

The  Perineal  Section. — The  urethra  is  opened 
by  a  median  perineal  section  and  the  prostate  ex- 
plored. 

The  Galvano-incision. — The  accompanying  fig- 
ure shows  the  instrument  employed  (Fig.  1T2). 
It  resembles  a  short,  stout  Bottini  incisor,  the 
knife  of  which  is  drawn  out  by  the  surgeon's  di- 
rect pull  instead  of  by  a  ratchet  wheel.  The 
length  of  the  incision  is  regulated  by  a  small  stop- 
pin,  which  may  be  set  at  any  desired  point.  The 
battery  is  the  same  that  is  required  for  the  Bottini 
operation.^  It  is  essential  to  allow  a  stream  of 
cold  water  to  course  from  the  meatus  through  the 
urethra  and  out  of  the  perineal  wound  while  the  burning  is  being  done. 
Otherwise  traumatic  stricture  will  result  from  overheating  of  the  per- 
ineal urethra.  The  instrument  must  be  tested  before  using  in  order  that 
the  amount  of  electricity  required  to  heat  the  knife  to  a  white  heat  may 
be  justly  appreciated. 

The  surgeon  introduces  the  instrument  into  the  perineal  wound, 
*It  should  give  a  constant  current  of  4  volts,  50  amperes. 


ii 


Fig.  172. — Chetwood's 
Prostatic  Incisor. 


OPERATIONS  OTHER  THAN  PROSTATECTOMY 


747 


and  turns  it  to  hook  over  the  prostate  in  the  required  direction.  He 
then  inserts  the  index  finger  of  his  left  hand  (protected  by  a  rubber 
glove)  into  the  rectum,  and  bears  down  with  the  point  of  the  instrument 
until  it  can  be  distinctly  felt  on  the  front  wall  of  the  rectum  above 
the  prostate. 

The  cooling  apparatus  having  then  been  adjusted  and  only  a  very 
small  stream  of  water  being  allowed  to  flow,  all  is  ready  to  begin.  From 
this  point  it  is  best  to  proceed  by  the  watch.  The  electricity  is  turned 
on,  and  five  seconds  are  allowed  for  the  knife  to  become  heated.     It  is 


Fig.  173. — Chetwood's  Perineal  Galvanoprostatotomy. 


then  very  slowly  withdrawn  ^  (Fig.  171),  from  sixty  to  ninety  seconds 
being  employed  in  drawing  it  out,  and  fifteen  seconds  for  its  return. 
The  instrument  is  then  extracted,  the  cold-water  nozzle  inserted  into  the 
perineum,  so  as  rapidly  to  cool  the  incised  tissues,  and  then  a  finger  is 
introduced  into  the  wound  and  the  groove  carefully  palpated.  It  should 
extend  on  an  even  plane  from  the  trigone  to  the  urethral  floor,  com- 
pletely dividing  the  bar. 

Frequently,  all  the  tissues  will  be  found  divided  with  the  exception 
of  the  urethral  mucous  membrane,  which  is  readily  torn  by  the  finger. 

» The  length  of  the  incision  varies  from  0.5  to  3  cm.  If  in  doubt,  the  surgeon 
may  better  make  a  short  incision  first  and  lengthen  it  later. 


748 


PROSTATE  AND  SEMINAL  VESICLES 


But  if  a  dense  bar  remains  this  should  be  divided  by  a  second  cau- 
terization. 

A  double-current  perineal  tube  is  inserted  and  after-treatment  con- 
ducted as  for  perineal  prostatectomy. 

Complications. — There  are  no  operative  complications  peculiar  to 
this  procedure.  The  postoperative  complications  are  similar  to  those  of 
perineal  prostatectomy.  Some  surgeons  find  the  operation  peculiarly 
productive  of  incontinence  of  urine.  I  have  employed  it  50  times, ^ 
with  but  2  deaths,  and  3  cases  of  grave  incontinence.    I  have  once  seen 


fL 


iy 


Fig.  174. — Young's  Prostatic  Punch. 


a  stricture  result  from  omission  of  the  cooling  water, 
series  shows  about  the  same  results. 


Dr.  Chetwood's 


THE  PUNCH  OPERATION   (YOUNG) 

The  operation  is  performed  in  the  cystoscopic  position,  under  local 
anesthesia. 


The  bladder  is  filled  with  1  to  100,000  bichlorid  of  mercury  solution  and 
the  operating  urethroscope,  with  the  obturator  in  place  or  with  the  inner 
tube  pushed  home  so  as  to  fill  the  fenestra,  is  inserted  imtil  the  beak  is  felt 
to  enter  the  bladder  for  a  very  short  distance.  The  inner  tube  is  then  with- 
drawn about  1.5  cm.,  enough  to  uncover  the  fenestra  and  the  cavity  is  dried  with 
swabs.  A  small  portion  of  the  floor  of  the  urethra  is  generally  seen  bulging 
into  the  fenestra,  sometimes  the  verumontanum.  The  instrument  is  then  gradu- 
ally pushed  deeper,  the  operator  at  the  same  time  looking  through  the  tube 
until  finally  the  median  bar  is  seen  to  "pop"  into  the  fenestra.  This  is  gen- 
erally accompanied  by  the  escape  of  a  small  amount  of  fluid  from  the  bladder 
into  the  tube,  but  by  drawing  the  instrument  slightly  oatward  this  is  stopped 
and  the  median  bar  is  found  finnly  held  in  the  fenestra  by  its  hooklike  inner 
margin  (Fig.  174).    The  inner  tube  is  then  simply  pushed  home  and  a  distinct 

*  Trans.  Am.  Urol.  Assn.,  1913,  xiii. 


PROSTATECTOMY  FOR  NEOPLASM  749 

resistance  will  be  met  with  while  a  large  section  of  the  median  bar  is  thus 
divided.  Without  removing  the  instrument  the  rongeur  forceps  are  inserted 
and  the  excised  specimen  removed.  It  is  generally  advisable  to  make  the  cut 
on  each  side  of  the  median  line  obliquely  outward  and  backward  in  order 
to  completely  remove  the  bar,  and  on  this  account  the  instrument  is  first  turned 
45°  to  the  right,  the  inner  tube  partly  withdrawn,  the  field  dried  with  a  swab, 
and  then  inspected  to  see  that  the  desired  portion  has  been  entrapped,  when  the 
tube  is  again  pushed  home  and  the  section  removed  as  before  with  the  forceps. 
The  left  lateral  oblique  portion  is  similarly  removed.^ 

A  double-current  urethral  catheter  is  then  introduced  and  con- 
tinuous irrigation  immediately  instituted  through  this.  The  bleeding 
maj  be  very  sharp  and  can  only  be  controlled  through  this  catheter  by 
incessant  watchfulness  and  repeated  injections  and  aspiration  of  clots, 
if  necessary.  The  catheter  is  usually  left  in  place  for  at  least  three  or 
four  days. 


UBETHEOSCOPIC  CAUTERIZATION  OF  THE  BLADDER  NECK 

Bottini  devised  a  most  efficient  cautery  but  his  operation  has  fallen 
into  disfavor  because  the  extent  of  cauterization  could  not  be  controlled. 
Chetwood  placed  the  operation  upon  a  sound  footing  by  adding  a 
perineal  section  and  the  control  of  palpation  both  before  and  after 
the  cauterization.  Goldschmidt,  Wossidlo,^  Bugbee,^  Day,^  and  others 
have  employed  various  forms  of  electricity  for  the  purpose  of  burning 
away  strictures  at  the  neck  of  the  bladder  under  urethroscopic  obser- 
vation. The  D'Arsonval  current  is  usually  employed  through  a  cysto- 
scope  or  urethroscope  permitting  observation  of  the  bladder  neck  and 
with  a  lever  attachment  which  will  direct  the  wires  to  make  pressure 
against  projecting  portions  of  the  bladder  neck  so  as  to  burn  through 
them.  The -wire  is  pressed  well  down  into  the  tissues  until  it  is  seen 
to  sink  into  them  in  a  groove  and  until  no  further  bubbles  ascend, 
showing  it  has  burned  as  deeply  into  the  tissues  as  may  be.  Inter- 
mittent catheterization  is  then  continued  so  long  as  the  obstruction 
requires  it. 

PROSTATECTOMY  FOR  NEOPLASM 

Extirpation  of  prostatic  carcinoma  requires  removal  of  the  whole 
prostate  together  with  its  capsule.  This  operation  was  first  performed 
by  Leisrink  in  1882,  a  similar  operation  was  perforaied  by  Fuller  in 
1898,  and  the  technic  has  been  finally  perfected  by  Young  (1904). 

^  Trans.  Am.  Assn.  G.-U.  Surg.,  1908,  iv,  231. 
'Surg.,  Gy'n.  4-  Obstet.,  August,  1915,  p.  208. 
"N.  Y.  State  Medical  Jour.,  1913,  xiii,  410. 
*Jour.  A.  M.  A.,  1915,  Ixv,  1797. 


750       •  PROSTATE  AND  SEMINAL  VESICLES 

Instruments  Required. — The  instruments  required  are  practically 
the  same  as  those  used  in  extra-urethral  prostatectomy. 

The  Operation. — The  patient  is  put  in  the  extreme  lithotomy  posi- 
tion, and  the  prostate  exposed  as  for  extra-urethral  prostatectomy.  But 
the  separation  of  the  rectum  from  the  prostate  should  be  carried  not 
only  to  the  upper  end  of  that  gland,  but  over  the  seminal  vesicles  as  well. 
After  these  structures  have  been  thoroughly  freed,  the  incision  is  made 
in  the  membranous  urethra  and  Young's  tractor  introduced  into  the 
bladder  and  opened.  The  handle  of  the  tractor  is  then  depressed  and 
the  membranous  urethra  divided  transversely  close  to  the  apex  of  the 
prostate. 

By  further  depressing  the  handle  of  the  tractor,  the  puboprostatic  liga- 
ment is  exposed  and  easily  divided  by  scissors,  thus  completely  separating  the 
prostate  from  all  important  attachments  (except  posteriorly).  The  lateral 
attachments,  which  are  slight,  are  easily  separated  by  the  finger.  The  posterior 
surface  of  the  seminal  vesicles  is  then  freed  by  blunt  dissection,  the  now  mobile 
prostate  being  drawn  well  out  of  the  wound.      (Young.) 

The  mass  is  then  drawn  strongly  downward  and  the  neck  of  the 
bladder  is  incised  in  the  middle  line  in  front,  and  about  1  cm.  above 
the  prostate.  The  incision  in  the  bladder  wall  is  continued  down  on 
each  side  until  the  trigone  is  exposed.  The  ureters  are  searched  for  and 
the  line  of  incision  carried  across  the  trigone  so  as  to  pass  1  cm.  in 
front  of  the  ureter  orifices.  By  blunt  dissection  the  base  of  the  bladder 
is  then  pushed  upward  from  the  anterior  surface  of  the  seminal  vesicles 
and  vasa  deferentia.  These  are  then  freed  from  the  bladder,  leaving 
as  much  of  the  fat  and  areolar  tissue  attached  to  the  vesicles  as  is  pos- 
sible. The  vasa  deferentia  are  drawn  down  by  a  blunt  hook  and  divided 
as  high  up  as  possible,  care  being  taken  not  to  damage  the  ureters.  The 
seminal  vesicles  then  come  down  more  easily.  Their  upper  ends  are 
ligatured  and  the  whole  mass  removed. 

Reconstruction  of  the  vesico-urethral  gap  is  now  necessary.  The 
stump  of  the  membranous  urethra  is  identified  by  the  passage  of  a 
catheter  from  the  meatus.  The  bladder,  which  has  retracted  far  up  into 
the  pelvis,  is  caught  with  forceps  and  drawn  down  again. 

The  first  suture  is  placed  by  inserting  the  needle  through  the  triangular 
ligament  above  the  urethra,  and  then  out  through  the  antei-ior  wall  of  the 
membranous  urethra,  then  through  the  anterior  wall  of  the  bladder  in  the 
median  line  from  within  out,  care  being  taken  to  include  only  the  submucosa 
and  the  muscle.  This  leaves  the  knot  outside  the  junction  of  the  two  approxi- 
mated edges.  The  thread  is  left  long.  Lateral  sutures,  including  the  periurethral 
muscular  structures  below,  and  two  posterior  sutures,  complete  the  anastomosis 
of  the  membranous  urethra  with  a  small  ring  into  which  the  anterior  portion  of 
the  margin  of  the  vesical  wound  has  been  fashioned  by  tying  the  sutures.  The 
remainder  of  the  vesical  wound  is  now  closed  with  sutures.     (Young.) 


OPERATIONS  UPON  THE  SEMINAL  VESICLES  751 

The  wound  is  freely  drained  with  gauze,  its  lateral  branches  being 
closed.    A  small  perineal  tube  should  be  left  in  for  a  week. 


OPERATIONS  UPON  THE  SEMINAL  VESICLES 

The  same  incision  as  that  used  by  Young  for  prostatectomy  is  ad- 
mirably adapted  to  operations  upon  the  seminal  vesicles.  The  operation 
is  begun  in  the  manner  described  above.  The  rectum  should  be  sepa- 
rated from  the  urethra  not  only  as  far  as  the  prostate,  but  also  beyond 
it,  to  reach  the  seminal  vesicle.  The  section  should  hug  the  prostate 
and  vesicle.  When  the  vesicle  is  reached  it  may  be  incised  (vesicu- 
lotomy) or  excised  (vesiculectomy).  As  the  wound  is  very  deep  the 
vesicles  are  brought  more  fully  into  view  by  catching  a  suture  in  each 
of  the  lateral  angles  of  the  prostate  and  making  traction  upon  this. 

Vesiculotomy.  1 — The  vesicle  is  thoroughly  exposed  by  division  of 
the  fascia  of  Denonvilliers  and  split  from  end  to  end  and  its  interior 
curetted.  A  tube  is  sutured  into  this  cavity  and  led  out  through  the 
perineal  wound,  which  is  closed  in  the  usual  manner.  This  drain  is 
kept  in  for  a  week. 

Vesiculectomy — The  sheath  of  the  vesicle  is  split  and  the  organ 
freed  by  blunt  dissection.  It  is  divided  at  its  entrance  into  the  pros- 
tate and  extracted  after  ligature  of  the  artery  at  its  fundus.  The  vas 
may  be  divided  and  extracted  with  it;  and,  if  preliminary  castration 
has  been  done,  the  whole  of  the  vas  may  be  pulled  out  through  the 
urethral  wound.  If  the  fundus  of  the  vesicle  is  adherent,  its  enucleation 
may  be  simplified  by  dividing  it  as  it  enters  the  prostate  and  endeav- 
oring to  shell  it  out  from  below  upward ;  but  this  maneuver  may  be 
extremely  difficult,  and,  inasmuch  as  the  vesicle  lies  immediately  below 
the  peritoneum  and  is  probably  adherent  to  this,  rather  than  risk  open- 
ing the  peritoneal  cavity,  it  may  seem  wiser  to  amputate  only  as  much 
of  the  vesicle  as  can  readily  be  freed,  and  to  be  satisfied  with  curetting 
or  cauterizing  its  remains. 

*Cf.  Squier,  Cleveland  Med.  Jour.,  1913,  xii,  801;  also  Barney,  Trans.  Am. 
Assn.  G.-U.  Surg.,  1914. 


CHAPTEE   LXXVI 

INTRAVESICAL   OPERATIONS 

LITHOLAPAXY 

Anesthesia. — Small  stones  may  be  cruslied  under  local  anesthesia; 
such  as  is  employed  for  cystoscopy.  The  operation  is  then  best  per- 
formed with  the  Chismore  combined  lithotrite  and  pump. 

For  multiple  stones,  stones  more  than  3  cm.  in  diameter,  or  com- 
plicated cases,  general  anesthesia  is  preferable. 

Instruments  Required — Besides  the  usual  antiseptics,  etc.,  a  kit  for 
suprapubic  section  should  be  at  hand  and  one  should  carry  all  special 
instruments,  lithotrites,  evacuators  and  tubes,  in  duplicate. 

Lithotrites. — The  lithotrite  (Fig.  175)  is  called  upon  to  perform 
two  very  different  functions — viz.,  to  crush  a'  stone  of  some  size  and 
perhaps  of  great  hardness,  and  to  catch  and  crush  small  crumbling 
fragments  that  are  only  just  too  large  for  aspiration.  For  the  former 
purpose  a  heavy,  powerful  lithotrite  with  a  fenestrated  female  blade 
(Fig.  176)  is  required,  while  for  the  latter  I  prefer  a  lighter  instru- 
ment with  a  solid  female  blade  of  a  broad  duck-bill  shape.  A  complete 
outfit  should  include  these  and  several  intermediate  varieties  of  litho- 
trites, as  the  surgeon's  judgment  dictates.  Small  lithotrites  are  made 
for  children. 

The  powerful  lithotrite  should  possess  several  characteristics:  (1) 
The  male  blade  when  screwed  home  should  pass  quite  through  the  fe- 
male blade:  an  instrument  thus  constructed  cannot  become  clogged; 

(2)  the  wheel  (Fig.  175)  or  globe  (Fig,  176)  handle  of  the  instrument 
must  be  large  enough  to  afford  firm  purchase  for  the  surgeon's  hand ; 

(3)  the  catch  for  adjusting  the  screw  action  should  be  sufficiently 
prominent  to  be  worked  without  the  least  difficult}'.  In  my  father's 
instrument  (a  modification  of  Eeliquet's)  the  catch  is  saddle-shaped 
(Fig.  175).  Chismore  had  added  to  his  lithotrite  an  automatic  hammer 
such  as  dentists  use,  and  with  it  claims  to  crush  the  hardest  and  largest 
stones  with  scarcely  any  effort. 

For  small,  soft  fragmients  a  flat-bladed,  duck-bill  instrument  is  use- 
ful. This  instrument  should  only  be  employed  toward  the  end  of  the 
operation.     The  nonfenestrated  blade  has  a  tendency  to  clog,  but  this 

752 


LITHOLAPAXY 


753 


instrument  will,  in  my  hand,  pick  up  fragments  that  no  other  lithotrite 
will  catch.  For  small,  hard  fragments  I  employ  a  light,  small-bladed 
fenestrated  instrument. 

The  Evacuator. — The  evacuator  or  washing-bottle  of  Bigelow  (Fig. 
177)  I  prefer  to  any  other.  The  evacuator  of  Chis- 
more  is  an  excellent  instrument. 

Tfas7im^-^w&es.— Litholapaxy  has  been  restricted 
bv  modern  surgery  to  such  simple  cases  that  almost 
any  standard  washing-tube  is  adequate.  I  have  em- 
ployed  Bigelow's,   my   father's,    and  Guyon's  with 

equal  success. 

The  Operation. — This  is  litholapaxy:    To  catch 

the  stone  with  an  instru- 
ment passed  through  the 
urethra,  to  frag-ment  it 
sufficiently  for  the  detri- 
tus to  pass  out  through  a 
tube,  and  to  suck  this  out 
by  some  suitable  appa- 
ratus. 

The  patient  is  placed 
upon  the  operating  table 
on  his  back,  with  his  feet 
widely   separated   and   a 
sand    bag    beneath    his 
hips.     He  is  then  cathe- 
terized  and   100   to   150 
c.c.   of  warai  boric  acid 
solution  injected  into  the 
bladder.     A  lithotrite,  se- 
lected in  accordance  with 
the  size  of  the  stone,  is 
then     introduced      (Fig. 
178).    It  may  have  to  be 
assisted  over  the  prostate 
by  pressure  on  the  peri- 
neum. 

The  surgeon  must  re- 
member that  the  specific 
gravity  of  the  stone  is 
scarcely  greater  than  that  of  the  water  in  which  it  floats.  The  least 
violent  move  of  the  lithotrite  dislodges  the  stone;  only  by  the  most 
gentle  and  deliberate  movements  can  it  be  grasped. 

Once  in  the  bladder  the  lithotrite  is  passed  gently  onward  until  it 


Fig.    175. — Bigelow 
Lithotrite. 


Fig.  17G. — Keyes  Lithotrite. 


Fig.  177. — Bigelow  Aspieator  and  Washing-ttjbe. 


Fig.   17b. — ^^Umwim;  mi.  Manner  of  Hcm.uin.,  tui;  I.i  i  ik  n  ui  ri:  when  Opening  and  Shut- 
ting IN  THE  Search  for  Fragments.     (.Morrow.) 

754 


LITHOLAPAXY 


755 


touches  the  wall  of  the  fundus.  The  male  blade  is  then  gently  with- 
drawn until  this  comes  in  contact  with  the  superior  wall  of  the  bladder 
neck,  the  handle  of  the  instrument  is  then  gently  elevated  so  that  its 
female  blade  forms  a  pouch  in  the  fundus  of  the  bladder.  The  instru- 
ment is  thus  held  for  a  brief  moment,  then  the  male  blade  is  very 
slowly  and  gently  pushed  inward  and  the  stone  will  usually  be  found 
within  the  grasp  of  the  instrument. 

The  screw  power  is  then  turned  on,  the  handle  given  a  fraction  of  a 


Fig.  179.- 


-Showing  the  Mannee  of  Holding  the  Bulb.     The  Left  Hand  Holds  the 
Weight  while  the  Right  Manipulates  It.     (Morrow.) 


turn  to  grasp  the  stone  tightly  and  the  whole  instrument  then  with- 
drawn toward  the  neck  of  the  bladder  to  prove  that  it  has  not  caught 
any  of  the  mucous  membrane  in  its  grasp.  If  the  instrument  moves 
freely  its  screw  handle  is  then  turned  slowly  and  intermittently  until 
the  stone  crumbles  into  fragments.  The  female  blade  is  then  returned 
to  its  original  position,  the  male  blade  withdrawn  and  the  maneuver  re- 
peated as  often  as  fragments  are  thus  caught  and  crushed.  From  one 
to  six  such  crushings  are  usually  required  to  reduce  the  stone  to  small 
fragTuents.  Then  the  lithotrite  is  once  again  passed  to  the  fundus,  and 
the  male  blade  withdrawn  to  the  bladder  neck  while  the  instrument  is 


756  INTRAVESICAL  OPERATIONS 

held  as  before  with  its  blades  in  the  median  line.  Then  it  is  turned  at 
right  angle  to  the  right  side  and  the  male  blade  gently  returned  toward 
the  female.  Small  fragments  are  usually  encountered  and  crushed  by 
this  maneuver  which  is  repeated  first  on  one  side  and  then  on  the  other 
until  fragments  larger  than  1  cm.  in  diameter  are  no  longer  caught. 
In  some  instances  the  last  large  fragment  can  only  be  caught  by  re- 
versing the  blades  and  closing  them  with  the  instrument  upside 
down. 

All  of  these  maneuvers  must  be  conducted  with  the  utmost  slowness 
and  gentleness. 

The  lithotrite  is  then  withdrawn  and  the  evacuating  tube  introduced 
and  attached  to  the  evacuating  bottle  full  of  boric  acid  solution.  With 
the  eye  of  the  tube  just  inside  the  bladder  neck  the  bulb  is  given  a 
sharp  pinch  of  sufficient  strength  to  evacuate  perhaps  one-third  of  its 
contents,  and  immediately  released.  As  the  rubber  reexpands  the 
solution  rushes  from  the  bladder  into  the  evacuator  carrying  with  it 
the  fragments  of  stone  which  sink  into  the  glass  collecting  bottle  at  its 
bottom.  This  maneuver  is  repeated  until  no  more  fragments  come 
away,  and  continued  thereafter  a  few  times  while  the  operator  notes 
whether  any  click  against  the  tube  announces  the  presence  of  any  fur- 
ther fragments  in  the  bladder.  If  he  believes  he  has  exhausted  most  of 
the  stone,  or  all  of  it,  a  lithotrite  with  a  solid  female  blade  is  intro- 
duced and  put  through  the  same  motions  as  above  described.  Whether 
any  fragments  are  thus  caught  and  crushed  or  not  it  is  wise  once  more 
to  evacute  so  as  to  certify  the  removal  of  the  last  fragment.  It  is  then 
prudent  to  close  the  operation  by  the  introduction  of  a  cystoscope 
whereby  the  bladder  can  be  visually  examined  and  the  absence  of  stone 
proven. 

The  unaccustomed  operator  may  be  misled  by  the  click  produced 
when  the  bladder  wall  catches  in  the  eye  of  the  tube.  This  is  a  muffled 
double  click  with  a  pull  to  it  quite  distinct  from  the  single  sharp  click 
of  a  stone  fragTiient.  By  moving  the  eye  of  the  instrument  to  another 
part  of  the  bladder,  contact  with  its  wall  is  readily  avoided. 

The  operation  is  concluded  by  an  irrigation  with  1 :  2,000  silver 
nitrate  solution. 

If  the  bladder  neck  has  been  so  bruised  that  the  fluid  contains  blood, 
a  catheter  should  be  tied  into  the  urethra  and  left  there  for  twenty-four 
hours,  or  longer  if  there  is  residual  urine.  But  in  most  instances  the 
bleeding  within  the  bladder  is  very  slight  and  no  after-treatment  is 
required. 

Difficulties  and  Complications — If  the  stone  cannot  be  grasped  it  is 
doubtless  adherent  to  some  part  of  the  bladder  wall,  and  suprapubic 
section  had  better  be  done  forthwith.  The  same  resort  is  open  to  the 
surgeon  who  fails  to  remove  the  last  fragment  or  breaks  his  lithotrite 


LITHOLAPAXY  757 

(this  accident  never  happened  to  my  father  in  150  operations;  it  has 
happened  to  me  once). 

I  have  once  seen  excessive  hemorrhage  in  the  course  of  a  litholapaxy 
due  to  the  presence  of  an  unsuspected  bladder  tumor. 

I  know  no  operation  of  which  the  success  depends  so  entirely  upon 
the  surgeon's  skill  and  technic.  What  is  most  difficult  to  the  novice  is 
to  crush  the  stone  methodically  and  deliberately.  The  first  catch  and 
crush  is  usually  easy^  and  perhaps  in  a  given  case  it  would  be  possible 
for  an  unskilled  operator  to  make  quick  work  of  the  larger  fragments 
without  any  particular  method;  but  long  before  the  last  fragment  has 
been  crushed  such  an  operator  will  find  himself  pottering  about  in  the 
bladder,  never  finding  any  considerable  fragment,  although  the  clicks 
upon  the  tube  assure  him  that  there  is  plenty  of  work  left  to  do.  This 
deadlock  may  continue  quite  indefinitely,  and  the  only  way  to  avoid 
it  is  to  know  in  exactly  what  part  of  the  bladder  the  stone  tends 
to  lie  and  in  exactly  what  part  of  the  bladder  the  beak  of  the  litho- 
trite  ij. 

After-treatment — The  course  of  water  and  hexamethylenamin  is  re- 
sumed as  soon  as  possible  after  operation. 

The  irritability  of  the  bladder  the  first  few  days  may  be  controlled 
by  morphin  or  by  opium  suppositories.  ISTitrate  of  silver  irrigations 
afford  great  relief. 

It  is  unwise  to  let  most  patients  get  up  before  four  days  have  passed. 
I  have  in  exceptional  instances  turned  my  patient  out  on  the  second  day. 
I  have  indeed  operated  in  my  office  several  times  under  local  anesthesia 
— and  with  no  anesthetic  in  the  case  of  small  stone — ^but  this  again  only 
in  exceptional  cases. 

The  after-treatment  cannot  be  considered  complete  until  the  patient 
has  been  cystoscoped  for  stone  one  month  after  the  operation,  nor  can 
any  assurance  be  given  that  no  fragment  has  been  left  behind  until  this 
search  has  been  performed. 

Postoperative  Complications. — After  litholapaxy  all  the  complica- 
tions may  occur  that  are  met  with  after  the  various  operations  upon  the 
urinary  tract :  retention,  hemorrhage,  urethral  fever,  cystitis,  prostatic 
abscess,  epididymitis,  or  even  the  graver  complications,  suppression, 
surgical  kidney,  even  pyemia  and  septicemia;  but  the  occurrence  of 
such  complications  indicates  that  the  surgeon's  skill  does  not  equal  his 
zeal.     I  have  never  lost  a  case  of  litholapaxy. 

Relapse  after  litholapaxy  may  occur  from  one  of  three  causes:  (1) 
A  fragment  may  be  left  by  the  operator;  (2)  a  new  stone  may  come 
down  from  the  kidney;  or  (3j  reaccumulation  may  occur  behind  an  en- 
larged prostate. 


758 


INTRAVESICAL  OPERATIONS 


HIGH  FREQUENCY  CAUTERIZATION  OF  BLADDER  LESIONS 


Since  the  introduction  of  the  high  frequency  current  used  through 
the  cystoscope  as  a  means  of  attacking  lesions  of  the  bladder  and  urethra 
by  Beer/  this  treatment  has  been  applied,  not  only  as 
first  suggested  for  the  cure  of  papillomata,  but  also 
for  the  healing  of  ulcers,  the  explosion  of  stones,  and 
the  cure  of  granulomata  in  the  urethra  as  well  as  the 
destruction  of  obstructions  at  the  bladder  neck 
whether  due  to  simple  prostatism  or  to  carcinoma. 

The  technic  for  burning  the  bladder  bar  has  been 
described  on  page  749 ;  that  for  urethral  granulomata 
and  bladder  papilloma  is  described  below.  The  at- 
tack upon  simple  or  tuberculous  ulcerations  by  this 
method  is  not  particularly  satisfactory.  I  have 
healed  with  it  one  case  of  simple  ulcer,  but  failed  in 
several  others. 

The  cauterization  of  bladder  papillomata  requires 
the  following  instruments : 

A  cystoscope  (preferably  of  the  so-called  opera- 
tive type)  ;  an  insulated  wire  or  flexible  metal  probe, 
and  an  electrical  source  for  the  high  frequency  cur- 
rent are  needed.  The  cystoscopic  and  electrical  in- 
struments made  by  Wappler  are  usually  employed. 
Inasmuch  as  diagnosis  as  well  as  treatment  may  be 
part  of  the  operation  one  also  requires  a  pair  of  for- 
ceps for  removing  specimens  from  the  neoplasm. 
The  operation  is  performed  as  follows: 
The  patient  is  cystoscoped  in  the  usual  manner. 
If  there  is  any  doubt  as  to  the  malignancy  of  the 
tumor  a  section  of  this  is  removed  by  the  cystoscopic 
forceps.  Forceps  and  telescope  are  then  withdrawn 
so  as  to  permit  the  bladder  to  empty  itself  of  the 
blood  which  follows  the  removal  of  the  specimen. 
The  electric  wire  is  then  introduced  with  the  tele- 
scope and  plunged  into  the  depths  of  the  tumor.  It  is  then  attached 
to  the  source  of  electricity  (see  below),  the  current  turned  on  for  an 
instant,  and  the  patient  asked  whether  he  feels  any  pain.  If  the  elec- 
trode is  properly  placed  no  pain  is  felt.  If  a  strong  current  is  used 
the  cystoscope  is  then  turned  off  so  that  its  lamps  may  not  be  burned 
out.  If  a  mild  current  is  used  one  may  observe  it  through  the  cysto- 
scope. As  soon  as  the  current  is  turned  on,  bubbles  begin  to  appear 
^Jour.  A.  M.  A.,  1910,  liv,  1768;   also  1912,  lix,  1784. 


kfl*y^* 


aot 


Fig.    ISO.— Operat- 
ing Cystoscope. 


CAUTERIZATION  OF  BLADDER  LESIONS 


759 


Y 


from  about  the  end  of  the  electrode,  and  the  tissues  near  it  become 
blanched  and  subsequently  black.  The  electrode  is  held  in  place  for 
about  thirty  seconds,  and  then  moved  to  another  part  of  the  tumor  and 
the  operation  repeated.  The  operation  is  thus  continued  by  repetitious 
burnings  of  various  portions  of  the  surface  of  the 
tumor  until  the  patience  of  the  operator  and  of 
the  victim  is  exhausted,  or  until  the  tumor  has 
become  completely  charred  over  its  surface. 

Some  operators  prefer  to  try  to  attack  the  base 
of  the  tumor  by  slipping-  under  its  overhanging 
fringes  and  endeavoring  to  burn  its  pedicle,  thus 
once  for  all  destroying  its  blood  supply.  This 
technic  seems  to  leave  the  patient  more  than 
usually  liable  to  gTave  postoperative  hemorrhage. 

After  the  operation  the  patient  should  rest 
relatively  quiet  for  twenty-four  hours,  and  then 
may  go  about  his  business.  If  the  bladder  be- 
comes irritated  the  best  injections  to  employ  are 
silver  nitrate  and  argyrol.  At  about  the  tenth  day 
sloughs  begin  to  separate  and  there  is  likely  to  be 
some  bleeding.  Exceptionally  this  bleeding  is 
very  grave.  I  have  twice  had  to  empty  the  pa- 
tient's bladder  of  clots  by  the  evacuating  tube  and 
several  deaths  have  been  reported  from  hemor- 
rhage. For  this  reason  the  patient  should  be 
within  call  of  an  experienced  physician  for  at 
least  two  weeks  after  each  operation.^ 

The  operation  is  repeated  every  two  weeks  un- 
til the  tumdr  has  been  apparently  burned  away. 
'No  note  need  be  taken  of  swellings  that  appear 
about  the  base  of  the  tumor,  for  such  a  swelling, 
though  it  looks  exactly  like  carcinoma,  is  due  to 
the  burning  itself. 

After  the  tumor  has  been  apparently  destroyed 
a  month  is  permitted  to  elapse,  then  a  confirma- 
tory cystoscopy  is  done.     This  should  be  repeated  after  six  months,  then 
after  a  year,  and  doubtless  thereafter  at  intervals  of  three  years. 

Recurrences  are  extremely  uncommon  excepting  in  the  outgrowth 
of  small  papillary  lesions  that  had  been  overlooked  at  the  time  the 
first  tumor  was  treated.  Only  one  relapse  in  situ  after  an  interval  of 
more  than  one  year  of  apparent  health  has  been  reported,- 

The  method  is  totallv  unsuited  for  the  treatment  of  infiltratine 

^  Trans.   Urol.  Assn.,   1915. 

*  Two  deaths  hv  rupture  of  the  bladder  have  been  reported. 


Fig. 


181 . C  YSTOSCOP- 

ic    Forceps. 


760  INTRAVESICAL  OPERATIONS 

bladder  gTowtlis.  Multixjle  papillomata  as  well  as  very  large  papil- 
lomata  may  be  removed  much  more  rapidly  bj  suprapubic  section  and 
cauterization,  to  be  followed  bj  intravesical  injection  and  treatment 
when  necessary. 

THE  CYSTOSCOPIC  FORCEPS 

Young  was  tbe  first  to  introduce  a  cystoscopic  forceps  for  tbe  pur- 
pose of  removing  foreign  bodies  or  specimens  from  tbe  growths  of  tbe 
bladder.  Buerger  ^  has  further  developed  this  method  and  devised  a 
very  ingenious  set  of  cystoscopic  instruments  whereby  specimens  may 
be  removed  from  doubtful  cases  of  tumor,  tuberculosis  or  other  bladder 
lesions ;  foreign  bodies  and  even  wee  stones  may  be  picked  up  (though 
stones  are  extremely  elusive)  ;  and  stricture  of  the  ureter  orifice  retain- 
ino;  stone  or  causing  intravesical  ureteral  cvst  mav  be  slit. 

The  cystoscopic  lithotrite  has,  unfortunately,  not  yet  been  perfected 
to  a  degree  permitting  its  general  use. 


CYSTOSCOPIC  EXTRACTION  OF  URETER  STONES 

The  passage  of  ureter  stones  may  be  encouraged  by  prodding  them 
with  the  ureter  catheter,  and  by  injecting  the  ureter  as  previously 
described.  If  the  stone  is  caught  at  the  very  orifice  of  the  ureter,  slit- 
ting with  the  urethroscopic  scissors  may  expedite  its  passage.  Small 
stones  may  also  sometimes  be  extracted  by  the  cystoscopic  alligator  for- 
ceps. Thus  far  the  eft'orts  made  to  reach  stones  higher  up  the  ureter 
and  to  extract  them  by  forceps  or  to  encourage  their  passage  by  me- 
chanical dilatation  of  the  ureter  have  proven  of  little  service.  Lewis  ^ 
reports  a  number  of  cases  showing  the  passage  of  stone  after  intra- 
urethral  manipulation. 

^Med.  Bee,  .June  21,  1913. 

'Hurg.,  Gyn.  #  Obstet.,  1915,  xx,  462. 


CHAPTER   LXXVII 
OPERATIONS  FOR  THE  CURE  OE  URINARY  FISTULA 

Treatment  of  fistulae  discliarging  urine,  whether  they  connect  with 
the  kidney,  the  ureter,  the  bladder,  or  the  urethra,  is  primarily  expect- 
ant. If  retention  is  not  present,  the  fistula  will  heal,  unless  there  is 
considerable  loss  of  tissue.  If  there  is  retention,  this  must,  of  course, 
be  removed  before  the  reestablishment  of  urinary  flow  through  the 
natural  passages  can  be  looked  for. 

Among  the  injections  employed  to  encourage  healing,  the  25  per 
cent  ethereal  solution  of  hydrogen  peroxid  is  generally  the  most  useful ; 
but,  if  all  else  fails,  operation  is  required  to  heal  the  fistula. 

The  surgical  principle  at  the  bottom  of  almost  all  the  operations 
undertaken  is  the  separation  of  the  visceral  and  cutaneous  ends  of  the 
fistula,  suture  of  the  visceral  orifice  (or,  if  the  fistula  is  between  two 
viscera,  suture  of  both  visceral  orifices),  and  the  interposition  between 
the  two  ends  of  the  fistulous  tract  of  a  thick  body  of  normal  tissues  after 
the  tract  itself  has  been  excised.  The  treatment  of  renal  fistula  forms 
almost  the  only  exception  to  this  rule. 

Tuberculous  fistulae  may  heal  spontaneously,  though-  they  have  ex- 
isted for  months.    Beyond  curettage,  surgery  helps  them  little. 

Carcinomatous  fistulae  do  not  heal. 


RENAL    FISTULA 

Urinary  fistula  in  the  loin,  following  operation  upon  the  kidney, 
will  always  heal  unless  there  is  obstruction  to  the  normal  urinary  out- 
flow, or  unless  there  remains  a  tuberculous  kidney  or  ureter  within  the 
loin.  The  operations  for  the  relief  of  these  fistulae  consist,  therefore, 
in  the  relief  of  urethral  or  renal  retention,  if  these  be  present,  or  in 
the  removal  of  the  disorganized  kidney  or  ureter.  Previous  to  opera- 
tion on  non-tuberculous  cases  an  attempt  to  encourage  the  closing  of 
the  fistula  by  the  prolonged  retention  of  a  ureteral  catheter  should  be 
made  if  this  is  practicable. 

Removal  of  ureteral  obstructions  has  already  been  discussed  (p. 
701).    ISTephrectomy  of  an  old  pyonephrotic  kidney  which  has  long  been 

761 


762 


OPERATIONS  FOR  URINARY  FISTULA 


fistulous  is  one  of  the  most  difficult  and  dangerous  operations  of  urinary 
surgery. 

Basing  his  practice  upon  the  researches  of  Hermann  and  l^icolai, 
Holt  ^  has  suggested  and  practiced  ligature  of  the  renal  pedicle  for  the 


-Tuberculous  Fistula  Following  Nephrectomy.     Since  it  does  not  run  to 
the  ureter,  operation  will  not  benefit  this  case. 

purpose  of  avoiding  the  difficulties  of  this  operation.  He  incises  the 
anterior  abdominal  wall  along  the  outer  edge  of  the  rectus,  pushes 
the  large  and  small  intestines  toward  the  median  line,  and  incises  the 
peritoneum  over  the  renal  vessels  to  the  outer  side  of  the  mesocolon. 
The  retroperitoneal  tissues  are  then  separated  toward  the  vertebral  col- 
umn until  the  renal  artery  and  vein  are  discovered.  If  the  adhesions 
are  so  dense  as  to  make  this  separation  difficult,  it  may  be  preferable  to 
incise  the  posterior  peritoneum  internal  to  the  colon,  and  proceed  with 
^Medical  Record,   1907,  June  22. 


VESICOVAGINAL  AND  VESICO-UTERINE  FISTULA  763 

the  ligature  of  the  renal  vessels  in  the  space  between  the  colic  arteries. 
The  artery  and  veins  are  tied  separately,  and  a  careful  search  made  to 
he  sure  that  no  accessory  renal  vessel  has  been  overlooked.  The  wound 
is  then  closed  in  the  usual  manner. 

I  have  never  had  to  resort  to  this  operation. 

URETERAL  FISTULA 

If  incomplete,  treatment  should  be  attempted  by  the  indwelling 
ureter  catheter ;  if  complete,  the  choice  is  between  reimplantation  of 
the  ureter  into  the  bladder,  the  bowel  or  the  skin,  or  nephrectomy  if  the 
opposite  kidney  is  sound  (Furniss  ^). 

HYPOGASTRIC  VESICAL  FISTULA 

Hypogastric  vesical  fistula  will  usually  close  if  the  urethral  obstruc- 
tion is  relieved  and  there  is  no  great  loss  of  tissue.  The  retained  ure- 
thral catheter  may  be  of  assistance.  Even  though  the  fistula  remains 
open  for  many  weeks  or  opens  and  closes  intermittently,  the  surgeon 
should  not  be  too  hasty  in  suggesting  operative  relief,  but  should  reserve 
this  for  cases  that  have  proven  absolutely  rebellious  for  months. 

The  operation  should  be  frankly  intraperitoneal.  It  consists  in  ex- 
cision of  the  fistulous  tract,  freeing  the  wall  of  the  bladder,  and  closure 
of  the  fistulous  orifice  in  the  bladder  wall  by  mattress  sutures,  re- 
enforced,  if  possible,  by  a  layer  of  Lembeii;  sutures.  The  abdominal 
wound  may  be  left  open,  or  the  muscles  may  be  caught  together  over 
a  small  drain.  The  retained  urethral  catheter  should  be  employed,  if 
possible. 

VESICOINTESTINAL   FISTULA 

The  operation  for  vesico-intestinal  fistula  consists  in  median  abdom- 
inal section,  isolation  of  the  loop  of  intestine  adherent  to  the  bladder 
(a  large  ureter  catheter  placed  in  the  fistula  may  be  of  assistance), 
emptying  and  clamping  of  the  gut,  separation  of  the  gnt  from  the  blad- 
der, closure  of  the  gut  by  enterorrhaphy  or  anastomosis,  and  closure 
of  the  bladder  orifice  by  mattress  suture.  The  retained  urethral  catheter 
and  drainage  to  the  point  of  suture  in  the  bladder  are  necessary. 

VESICOVAGINAL  AND  VESICO-UTERINE  FISTULA 

Vaginal  Fistula. — The  patient  is  placed  in  tlie  lithotomy  position 
and  the  vaginal  orifice  of  the  fistula  exposed  and  liberated  by  a  circular 
^Am.  Jour,  of  Obstet.,  1915,  Ixxxii,  No.  5. 


764  OPERATIONS  FOR  URINARY  FISTULA 

incision.  This  incision  is  carried  up  about  the  fistula  until  the  mucous 
membrane  has  been  freed  up  to  the  bladder.  The  fistula  is  then  turned 
inside  out,  as  it  were,  into  the  bladder  and  caught  by  one  or  two  sub- 
mucous sutures.  The  vesicovaginal  septum  is  then  sutured  with 
chromic  gut,  and  afterward  the  vaginal  wall  sutured  over  all  with  simple 
catgut. 

The  bladder  should  be  drained  by  a  retained  catheter. 

Vesico-uterine  Fistula — The  closure  of  vesico-uterine  fistula  is 
extremely  difficult.  The  operation  of  choice  is  total  hysterectomy  with 
suture  of  the  bladder  wall  in  layers.  Exceptionally  the  fistula  enters 
the  lower  part  of  the  cervix  and  can  be  cured  by  excision  of  the  fistulous 
tract  and  suture  of  the  bladder  in  layers. 


URETHRORECTAL  FISTULA 

The  treatment  of  urethrorectal  fistulae  depends  largely  upon  the 
size  of  the  opening  in  the  rectum.  If  this  is  so  small  that  it  can  only 
be  felt  as  a  dimple,  the  pockets  of  granulation  tissue  and  pus  between 
the  rectum  and  the  bowels  should  be  opened  by  a  median  or  bilateral 
perineal  incision,  the  fistulous  tract  carefully  curetted  throughout  and 
all  pockets  freely  opened  into  the  main  channel  leading  to  the  perineum, 
care  being  taken  not  to  enlarge  the  actual  opening  in  the  mucosa  of  the 
rectum.  A  perineal  tube  is  then  left  in  place  for  about  a  week.  On 
its  removal  a  urethral  catheter  is  inserted  and  left  in  place.  In  the 
course  of  three  weeks  the  rectal  fistula  should  be  healed  and  the  urinary 
fistula  down  to  a  granulating  point. 

This  operation  is  the  more  likely  to  succeed  if  suprapubic  drainage 
is  employed  to  divert  the  stream  of  urine. 

If  the  hole  into  the  rectum  is  half  a  centimeter  or  so  in  diameter 
the  above  operation  will  fail.  The  treatment  then  depends  upon 
whether  the  patient  is  greatly  inconvenienced  by  his  fistula,  notably 
whether  it  tends  to  pocket  and  burrow,  and  also  whether  it  communi- 
cates with  the  perineum. 

Such  patients  often  arrive  at  the  hospital  in  a  deplorable  condition 
with  a  perineum  full  of  irregTilar  pocketing  sinuses.  The  first  opera- 
tion should  then  simply  be  a  house-cleaning  one,  consisting  of  incision 
and  curetting  with  the  object  of  reducing  the  sinuses  to  a  single  central 
straight  fistulous  tract. 

Though  the  resultant  fistula  be  relatively  small  it  is  imbedded  in 
such  a  mass  of  scar  tissue  that,  unless  it  causes  the  patient  grave  incon- 
venience, it  is  often  wise  not  to  attempt  any  further  operation.  IMost 
of  the  procedures  that  have  been  suggested  for  the  treatment  of  these 
conditions  only  leave  the  patient  in  a  worse  state  than  he  was  in  before. 


PENILE  FISTULA  '  765 

Young  and  Stone  ^  report  the  cure  of  three  complicated  cases  bj 
the  operation  of  Tedenat.  This  begins  with  the  establishment  of  a 
suprapubic  fistula ;  then  the  anus  is  circumscribed  by  an  incision  divid- 
ing the  mucosa  at  the  mucocutaneous  margin,  and  extending  anteriorly 
along  the  median  line  of  the  perineum,  thus  having  a  racquette  shape. 
The  mucous  membrane  of  the  bowel  is  freed  as  in  the  Whitehead  opera- 
tion high  enough  to  permit  the  orifice  of  the  fistula  to  appear  outside  of 
the  anus.  This  loosening  is  assisted  by  deepening  the  ''handle"  of  the 
racquette-shaped  incision  in  the  midline  of  the  perineum  in  front,  and 
division  of  the  fistula  between  the  rectum  and  the  urethra.  The  ure- 
thral end  of  the  fistula  thus  laid  bare  is  then  carefully  sutured  and 
healthy  tissues  brought  from  side  to  side  to  protect  it.  Four  stay 
sutures  of  chromic  gait  are  then  taken  in  the  rectum  to  hold  it  down,  the 
excess  including  the  rectal  orifice  of  the  fistula  cut  away,  the  rectal  edge 
sewed  to  the  skin  after  the  sphincter  muscle  and  the  levatores  have 
been  pulled  together  in  front  by  stout  chromic  gait  sutures  in  order  to 
reconstruct  the  perineum. 

If  the  above  operation  is  impossible,  the  fistula  may  be  changed 
into  a  urethroperineal  one  by  Albarran's  procedure  of  freei-ng  the  rec- 
tum by  a  posterior,  U-shaped  incision  carried  up  to  beyond  the  point 
of  fistula.  Lateral  incisions  are  then  made  in  the  rectal  wall  and 
carried  forward  to  meet  in  a  V  above  the  fistulous  orifice  on  the  anterior 
wall  of  the  rectum.  The  two  edges  of  this  V  are  then  united  so  as  to 
leave  a  urethral  channel  running  to  the  perineum.  The  posterior  edges 
of  the  V  are  also  then  united,  thus  isolating  the  rectum  from  the  new 
urethroperineal  fistula.  After  healing  has  taken  place,  the  urethro- 
j)erineal  fistula  is  closed  by  a  secondary  operation. 

URETHROPERINEAL  FISTULA 

Perineal  urethral  fistulae  will  almost  always  close,  unless  they  are 
tuberculous  or  cancerous,  by  the  lapse  of  time,  if  the  caliber  of  the  ure- 
thra is  kept  open  by  sounds,  and  the  fistula  repeatedly  curetted.  If 
these  means  fail,  the  fistula  may  be  closed  by  free  dissection  of  the 
perineum,  excision  of  the  scar,  and  suture  of  the  urethra,  over  which 
is  drawn  a  thick  layer  of  the  urethral  and  perineal  muscles.  The  urine 
should  be  diverted  through  a  urinary  fistula. 

PENILE  FISTULA 

The  pinpoint  fistula  that  results  from  suppuration  of  a  urethral 
gland  rupturing  into  the  f  renum  of  the  prepuce  should  never  be  operated 

^  Trans.  Am.  Assn.  of  G.-TJ.  Surgeons-^  1913^  viii,  270. 


766  OPERATIONS  FOR  URINARY  FISTULA 

upon.  It  may  almost  always  be  cured  by  injections  of  25  per  cent 
ethereal  solution  of  peroxid  of  bydrogen  into  the  inner  orifice  of  tbe 
fistulae  after  tbe  surrounding  parts  have  been  protected  by  vaselin. 
Operation  almost  inevitably  leaves  a  larger  bole  tban  was  tbere  before. 

Otber  penile  fistulae  also  usually  do  much  better  under  expectant 
treatment  by  opening  abscesses,  curetting  tbe  fistula,  passing  sounds, 
and  awaiting  bealing,  tban  tbey  do  under  any  plastic  operation. 

Tbe  great  source  of  failure  in  attempted  plastic  operations  upon 
tbe  penis  is  tbe  absence  of  blood  supply  in  tbe  flaps  and  tbe  presence 
of  urine.  A  suprapubic  or  perineal  fistulization  of  tbe  bladder  sbould 
therefore  be  a  preliminary  to  every  operation,  and  the  flaps  sbould  be 
made  in  such  a  way  as  to  have  the  greatest  possible  vitality.  I  have 
succeeded  once  or  twice  in  closing  relatively  small  fistulae  by  turning 
them  inside  out  by  means  of  a  needle  sutured  to  tbe  skin  end  of  tbe 
fistula  after  it  had  been  dissected  as  free  as  possible,  which  needle  was 
then  pushed,  blunt  end  first,  into  the  urethra  and  out  of  the  meatus,  in- 
verting the  fistula  in  behind  it.  The  peri-urethral  tissues  are  then 
sutured. 


CHAPTER   LXXYIII 

OPERATIONS  FOR  MALFORMATIONS   OF  THE  URETHRA  AND 

BLADDER 

MEATOTOMY 

Antisepsis. — The  tip  of  the  penis  should  be  well  cleansed  with  soap 
and  water  and  bichlorid,  and  the  terminal  portions  of  the  anterior  ure- 
thra irrigated  with  a  1 :  5,000  solution  of  the  latter. 

Anesthesia.- — A  minute  bunch  of  cocain  crystals,  or  a  fragment  of  a 
cocain  tablet  is  inserted  within  the  meatus  and  dissolved  by  instilling 
upon  this,  with  a  medicine  dropper,  a  few  drops  of  1 :  1,000  adrenalin 
solution. 

Anesthesia  is  completed  within  five  minutes,  by  which  time  a  dis- 
tinct blanching  of  the  tip  of  the  penis  is  noticed. 

The  Operation — A  blunt-pointed,  straight  bistoury  is  introduced 
into  the  urethra,  the  floor  of  which  is  cut  by  an  outward  sweep  of  the 
instrument.  With  the  bulbous  bougie  the  patency  of  the  canal  is  then 
tested,  and  any  bands  that  require  further  division  are  cut.  If  the 
meatus  internus  is  narrow,  this  may  be  cut  with  the  bistoury,  although 
some  surgeons  prefer  to  use  the  urethrotome  for  this  purpose.  All  in- 
cisions should  be  made  upon  the  floor  of  the  canal. 


OPERATION  FOR  RUPTURE  OF  THE  URETHRA 

When  the  urethra  is  ruptured  in  its  penile  portion,  the  indwelling 
catheter  will  usually  prevent  complications,  though  if  large  hematoma 
occurs  this  should  be  incised,  and  through  this  incision  the  urethral 
walls  may  be  sutured.  For  perineal  rupture,  immediate  median  peri- 
neal section  should  be  performed.  If  a  slight,  or  partial,  rupture  is  en- 
countered, clots  are  cleared  away  and  a  perineal  tube  inserted. 

If  the  rupture  is  complete,  retrograde  catheterization  identifies  the 
posterior  segment  of  the  urethra  and  leaves  a  suprapubic  wound  for 
derivation  of  the  urine. 

If  there,  is  too  much  loss  of  tissue  to  permit  suture  of  the  urethra, 
no  plastic  operation  should  be  attempted,  but  an  indwelling  catheter 
is  inserted,  which  is  introduced  into  the  meatus  and  out  through  the 

767 


768 


OPERATIONS  UPON  THE  URETHRA  AND  BLADDER 


perinea]  wound,  then  in  from  the  perineal  wound  and  into  the  bladder. 
If  fistula  persists  this  requires  secondary  operation. 

OPERATIONS  FOR  HYPOSPADIAS 


Beck's  Operation. — This  consists  in  liberating  the  urethra,  bring- 
ing it  forward  and  suturing  it  to  an  orifice  punched  through  the  glans. 
The  urethra  must  be  freed  well  back  and  sutured  to  the  apex  of  the  glans 
to  prevent  incurvation  (Figs.  183,  184,  185).     This  operation  is  ap- 


FiG.  183. — Beck's  Operation  for  Balani- 
Tic  Hypospadias.  Liberation  of  the  ure- 
thra— puncture  of  the  glans. 


Fig.  184. — Beck's  Operation  for  Balani- 
Tic  Hypospadias.  The  urethra  drawn 
through  the  glans. 


plicable  only  to  balanitic  hypospadias  and  to  a  penis  without  any  con- 
genital incurvation. 

Operation  for  Penile  Hypospadias. — For  jienile  hypospadias  the 
operations  are  many  and  various.  Certain  preliminary  steps  are  neces- 
sary in  almost  all  cases. 

First,  the  penis  must  be  freed  from  its  scrotal  adhesions.  If  these 
are  slight,  a  transverse  incision  through  the  penoscrotal  frenum  will, 
when  sutured  in  a  longitudinal  direction,  suffice  to  free  the  organ.  But 
if  the  penis  is  deeply  buried  in  the  scrotum  the  integument  of  the  former 
must  be  derived  from  the  latter  with  regard  only  to  covering  in  the 


OPERATIONS  FOR  HYPOSPADIAS 


769 


penis;  tlie  scrotum  will,  by  virtue  of  its  looseness,  adapt  itself  to  the 
loss  of  almost  any  amount  of  skin. 

Secondly,  the  incurvation  of  the  body  of  the  penis  often  demands 
attention.     This  may  be  corrected  through  the  liberating  incision.     A 
transverse  incision  is  carefully  made  through  the  whole  thickness  of 
the  sheath  of  the  corpora  cavernosa  on  its  under 
surface,  care  being  taken  to  avoid  the  erectile 
tissue.      This    is    usually    sufficient    to    permit 
straightening  the  penis.     If  not,  the  intercav- 
ernous septum  may  require  division  down  to 
the  dorsum.    Then  the  penis  is  forcibly  straight- 
ened and  snugly  bandaged  about  a  slight  splint 
in  an  overextended  position  to  prevent  recon- 
tracture.    1  can  vouch  from  personal  experience 
for  the  satisfactory  results,  obtainable  by  this 
somewhat  violent  procedure. 

Finally,  comes  the  most  delicate  part,  of  the 
treatment — the  extension,  namely,  of  the  ure- 
thra to  its  proper  length.  Great  ingenuity  has 
been  displayed  in  the  formation  of  the  new 
canal.  The  operations  of  Duplay,  Thiersch, 
Dieffenbach,  Dolbeau,  Laurent,  and  Van 
Hook  ^  deserve  mention.  In  each  of  these  the 
lining  membrane  of  the  new  canal  is  derived, 
in  one  way  or  another,  by  flaps  turned  in  from 

the  adjoining  regions.  That  each  has  been  devised  to  supplement  the 
older  ones  is  an  evidence — to  which  the  surgeon  who  has  tried  any  will 
certainly  testify — of  how  rarely  they  succeed  and  how  utterly  baffling 
the  condition  is. 


Fig.  185. — Beck's  Opera- 
tion FOR  Balanitic  Hy- 
pospadias.    Suture. 


Mayo's  Operation. — The  prepuce  is  extended  as  for  circumcision  and  two 
incisions  are  made  about  one  inch  apart  extending  from  its  free  border  to  its 
attachment.  The  prepuce  is  unfolded,  forming  a  loop  of  thin  skin  about  two 
and  one-half  inches  in  length.  Should  this  not  be  considered  sufficient  to 
reach  from  its  attachment  to  the  hypospadic  opening,  the  two  incisions  are 
extended  back  along  the  dorsum  of  the  penis  until  sufficient  tissue  is  obtained, 
when  the  two  incisions  ai'e  connected  by  a  transverse  one  and  the  flap  of  skin 
lifted  but  left  attached  to  the  penis  at  its  base.  Several  sutures  now  close  the 
lateral  integaunent  of  the  penis  over  the  dorsal  area. 

The  pedunculated  flap  of  prepuce  is  constructed  into  a  tube  with  its  skin 
or  inner  surface  inside,  by  means  of  a  number  of  calgut  sutures.  The  penis  is 
tunnelled  by  means  of  a  sharp  bistouiy  or  trocar  and  cannula  through  the  glans, 
above  its  groove,  along  the  penis  to  a  point  beneath  the  hypospadias  opening, 
when  it  is  made  to  emerge  at  one  side  of,  but  close  to,  the  urethra.  The  tube 
of  prepuce  is  drawn  through  the  tunnel  and  sutured  where  it  enters  the  glans 
and  also  where  it  emerges. 

^Cf.  Mayo,  Jour.  Am.  Med.  Assn.,  1901,  xxxvi,  1157. 


770 


OPERATIONS  UPON  THE  URETHRA  AND  BLADDER 


Ten  days  later  the  new  urethra  is  cut  free  from  the  remains  of  the 
prepuce. 

Six  months  or  a  year  later  the  urine  is  diverted  through  a  perineal 


Fig.  186. — Rochet's  Modified  Nove- 
JossERAND  Operation  for  Hypo- 
spadias. The  flaps  are  cut,  the  cath- 
eter introduced,  the  scrotal  flap  su- 
tured around  it. 


Fig.  187. — Rochet's  Modified  Nove- 
JossERAND  Operation  for  Hypospa- 
dias.   The  final  sutures. 


or  suprapubic  fistula  and  the  adjoining  orifices  of  the  old  and  new 
uiethrae  united. 

I  have  employed  with  one  complete  success  and  one  partial  failure, 
the  Rochet-Xove-Josserand  operation,  which  avoids  many  of  the  diffi- 
culties encountered  in  other  procedures. 

Nove-Josserand's  Operation. — Through  a  transverse  incision  2  cm. 
long  and  just  in  front  of  the  hypospadic  meatus,  a  stout  probe  is  intro- 
duced and  passed  forward  along  the  under  surface  of  the  penis,  in  the 
subcutaneous  connective  tissue,  until  it  reaches  the  base  of  the  glans, 


OPERATIONS  FOR  HYPOSPADIAS  771 

elevating  the  skin  from  the  entire  under  surface  of  the  penis.  The  an- 
terior orifice  of  the  canal  is  then  formed  by  slitting  up  the  under  surface 
of  the  glans,  or  by  puncturing  it  with  a  trocar.  To  obtain  an  epithelial 
lining  for  this  canal — and  herein  consists  the  originality  of  the  opera- 
tion— an  Oilier  ^  skin-graft,  4  cm.  wide  and  considerably  longer  than 
the  intended  canal,  is  taken  from  the  inner  side  of  the  thigh,  where 
there  are  no  hairs,  and  wrapped,  inside  out,  around  a  woven  catheter, 
21  French  in  size,  and  held  in  place  by  a  ligature  at  each  end  and  one 
or  two  sutures,  all  of  00  catgut.  (Rochet  ^  employs,  instead  of  the  Oi- 
lier gTaft,  a  flap  taken  from  the  scrotum,  with  its  base  at  the  abnormal 
urethral  orifice.  This  device  eliminates  the  fistula  between  the  old 
urethra  and  the  new  (Figs.  186,  187).)  The  catheter  thus  covered  is 
then  inserted  into  the  canal,  and  when  the  graft  is  in  place  the  anterior 
ligature  is  cut  and  removed,  and  the  edge  of  the  graft  sutured  to  the 
glans  penis.  The  catheter  is  then  cut  off  short  so  that  each  end  barely 
protrudes  from  the  canal,  and  a  snug  dressing  is  applied  with  the  penis 
held  in  the  erect  position.  A  retained  catheter  is  used  to  dra^w  off  the 
urine.  (In  the  Rochet  operation  the  catheter  around  which  the  graft 
is  wrapped  is  used  as  a  retained  catheter.)  On  the  eighth  day  the  pos- 
terior ligature  is  cut  and  the  catheter  removed.  Five  days  later  the 
daily  passage  of  sounds  is  begim  and  continued  for  three  weeks. 

The  Xove-Josserand  operation  has  been  still  further  modified  by  its 
originator,^  as  follows : 

As  a  first  step,  three  operative  procedures  are  performed : 

1.  The  incurvation  is  corrected  by  incision  of  the  fibrous  enve- 
lopes of  the  corpora  cavernosa. 

2.  The  bulbous  urethra  is  incised  for  a  distance  of  at  least  4  cm. 
and  sutured  to  the  skin  of  the  perineum,  thus  forming  a  perineal  ure- 
throstomy. ' 

3.  The  edges  of  the  hypospadic  meatus  are  incised  and  sutured  to 
each  other,  so  as  to  close  its  orifice  permanently. 

Six  or  eight  weeks  later  the  second  operation  is  performed,  as 
follow^s : 

1.  The  meatus  is  reopened  by  a  simple  longitudinal  incision. 

2.  By  means  of  a  trocar  a  canal  is  bored  in  the  subcutaneous  tis- 
sues of  the  penis  from  the  hypospadic  meatus  to  the  glans  penis.  This 
canal  is  sufficiently  dilated  to  admit  a  ISTo.  20  French  sound.  It  is  then 
compressed  for  a  few  moments  in  order  to  check  the  bleeding. 

^The  oilier  graft  differs  from  the  Thiersch  graft  in  that  it  is  made  as  thick  as 
possible  without  including  any  of  the  subcutaneous  tissue,  instead  of — as  in  the 
Thiersch  method — as  thin  as  possible. 

^Guyon's  Annales,  1900,  xviii,  648. 

'Arch.  gen.  de  Chir.,  1909,  No.  25. 
See  also  Jour  d'Urol,  1914,  v,  393. 


772     OPERATIONS  UPON  THE  URETHRA  AND  BLADDER 

3.  A  graft  consisting  of  the  whole  thickness  of  the  true  skin,  half 
again  as  long  as  the  new  urethra  and  about  4  cm.  wide,  is  taken  from  the 
antero-external  surface  of  the  thigh.  This  is  sutured,  skin  side  inward, 
about  a  soft-rubber  catheter,  size  18  French.  Three  fine  catgut  sutures 
are  employed. 

4.  A  fine  dressing  forceps  is  introduced  from  before  backward 
through  the  newly  tunneled  canal  and  withdrawn,  carrying  the  catheter 
and  graft  with  it.  The  graft  should  extend  well  beyond  each  end  of  the 
new  canal.  The  catheter  is  fixed  in  place  by  a  silk  suture  attaching  it 
to  the  glans. 

On  the  eighth  day  a  silk  suture  is  tied  to  the  end  of  the  catheter  and 
this  is  gently  withdrawn,  carrying  the  silk  suture  into  the  new  canal, 
where  it  is  left. 

Thereafter  the  new  canal  is  gently  irrigated  once  a  day  with  boric 
acid  solution. 

On  the  fourth  day  after  removal  of  the  catheter,  the  silk  suture 
is  tied  to  the  tip  of  a  No.  12  French  bougie,  which  is  thus  gently  drawn 
through  the  new  canal  and  withdrawn  again,  leaving  the  silk  thread 
still  in  place.  This  sounding  is  repeated  with  instruments  no  larger 
than  1^0.  15  French  twice  a  week  for  two  months,  the  silk  suture  being 
employed  as  a  guide  the  first  three  or  four  times.  Thereafter  dilatation 
is  carried  up  to  ISTo.  20  French,  and  if  there  is  any  difficulty  in  this 
operation  the  canal  is  widened  by  urethrotomy  upon  the  roof.  About 
two  months  more  are  required  to  obtain  a  canal  of  sufficient  caliber,  and 
during  this  time  the  fistula  at  the  junction  of  the  new  and  old  urethras 
may  be  expected  to  close.  When  this  has  occurred,  the  perineal  fistula  is 
closed  by  a  third  operation.  The  mucous  membrane  of  the  urethra  is  cut 
away  from  its  attachment  to  the  skin  and  freely  separated  from  the  in- 
tervening tissues.  The  urethra  itself  is  sutured  and  the  soft  parts 
sutured  over  it,  the  skin  wound  being  left  open. 


OPERATIONS  FOR  EPISPADIAS 

The  cure  of  epispadias  requires  two  operations: 

1.  Closure  of  the  sphincter. 

2.  Formation  of  a  new  canal. 

The  Sphincter,^ — Trendelenburg  states  that  the  sphincter  may  be 
adequately  tightened  by  excision  of  a  broad  wedge-shaped  piece  of  the 
orifice  and  suture. 

Formation  of  a  New  Canal. — This  may  be  done  by  a  flap  operation 
or  by  the  Nove-Josserand  procedure. 


OPERATIONS  FOR  EXSTROPHY  773 

OPERATIONS  FOR  EXSTROPHY 

Three  varieties  of  operation  may  be  recognized : 

1.  Obliteration  of  the  bladder. 

2.  The  formation  of  a  new  bladder. 

3.  Diversion  of  the  stream  of  urine. 

With  each  of  these  the  radical  cure  of  hernia  may  be  combined. 

1.  Obliteration  of  the  Bladder  ( Sonnenberg  ^ ) . — This  operation 
attempts  but  little.  The  mucous  membrane  of  the  bladder,  or  the  whole 
bladder  wall,  is  removed,  and  some  attempt  is  made  by  skin-grafting  or 
flap-raising  to  bring  the  abdominal  wall  together  and  so  to  remove  the 
large  raw  surface  of  the  bladder  and  to  substitute  scar  or  skin  in  its 
place.  The  ureters,  with  the  mucous  membrane  around  their  orifices, 
are  displaced  downward  and  sutured  to  the  end  of  the  penile  groove, 
which  may  be  closed  previously  or  simultaneously  by  one  of  the  opera- 
tions for  epispadias.  Thus  the  object  of  the  operation  is  to  improve  the 
patient's  condition  to  the  extent  of  leaving  him  with  a  manageable  in- 
continence by  removing  the  sore  and  stinking  bladder.  The  operation 
is  singTilarly  unsuccessful. 

2.  The  Formation  of  a  New  Bladder  (Autoplastic  Method). — This 
operation  is  the  ideal  one,  but  it  is  an  ideal  that  has  not  been  realized 
in  practice.  Until  some  one  shall  produce  a  sphincter  for  the  bladder 
the  patient's  capacity  to  hold  his  urine  after  operation  will  be  nil. 

The  operations  may  be  described  as : 

a.   Suture  of  the  bladder  itself. 
6.  The  flap  operation. 
c.  Closing  the  symphysis. 

As  a  preliminary  to  operation,  hexamethylenamin  should  be  admin- 
istered to  keep  the  urine  sweet,  and  ureteral  catheters  should  be  intro- 
duced to  keep  the  wound  dry. 

The  ideal  method  theoretically  is  to  dissect  up  the  bladder  wall,  to 
turn  it  over,  and  to  suture  it  so  as  practically  to  form  a  new  bladder. 
There  are  two  causes  of  failure.  In  the  first  place  the  bladder  is  so  con- 
tracted that  there  is  scarcely  any  tissue  to  work  on.  Pousson,"  in  order 
to  overcome  this,  boldly  enters  the  peritoneal  cavity,  inverting  the  blad- 
der, peritoneal  coat  and  all,  and  then  closing  off  the  general  peritoneal 
cavity  (but  he  reports  only  one  case,  and  that  a  failure).     In  the  second 

^Berlin.  Idin.  Wochensclir.,  3  882,  six,  471. 
'Guyon's  Annales,  1898,  xvi,  1223. 


774    OPERATIONS  UPON  THE  URETHRA  AND  BLADDER 

place,  in  spite  of  ureteral  catheters  and  constant  changes  of  dressings, 
urine  gets  into  the  wound,  which  granulates  instead  of  healing,  with  the 
result  that  the  sutures  tear  out. 

The  flap  operation  has  been  developed  by  the  ingenuity  of  Eoux, 
Thiersch,  Pancoast,  Ayres,  Holmes,  and  many  others.  (Cf.  Pousson.) 
One  or  two  flaps  taken  from  the  surrounding  skin  are  turned  in  to  form 
the  anterior  wall  of  the  bladder,  and  the  raw  surface  thus  left  is  cov- 
ered in  as  far  as  possible  by  other  flaps.  This  operation  often  succeeds 
after  many  partial  failures,  but  the  hairs  that  ultimately  grow  from 
the  inverted  skin  become  incrusted  with  phosphates,  and  the  patient 
finds  his  partial  relief  not  worth  the  having.  Eecent  experimenters 
have  suggested  filling  in  the  gap  with  a  segment  of  the  g-ut  (Tizzoni 
and  Poggi,  Enderlin^),  and  this  operation  has  been  performed  once 
successfully  on  a  man  by  Kutkowski,^  whose  patient,  eight  weeks  after 
operation,  could  retain  25  c.c.  of  urine.  The  defect  in  the  bladder  wall 
in  this  case  was  not  a  large  one.  The  gut  used  was  the  ileum,  which  was 
left  attached  to  its  mesentery.  Manifestly  such  an  operation  is  not 
without  its  dangers  both  immediate  and  remote. 

Attempts  at  closing  the  symphysis  in  order  to  diminish  the  gap  to  be 
covered  over,  and  at  the  same  time  to  attempt  the  formation  of  a  sphinc- 
ter, have  not  been  successful.  Trendelenburg  applies  a  belt,  hoping 
by  its  pressure  to  approximate  the  bones,  and  if  this  fails  he  opens 
the  sacro-iliac  synchondrosis  on  each  side.  This  operation  is  not  ap- 
plicable to  children  over  eight  years  of  age,  and  its  results  have  been 
quite  universally  unsatisfactory,  though  Delageniere  reports  a  case  in 
which,  after  seven  supplementary  operations,  he  obtained  a  radical  cure 
and  a  satisfactory  sphincter.  Berg  has  employed  osteotomy  of  both 
iliac  bones.  IsTot  enough  work  has  been  done  along  any  of  these  osteo- 
plastic lines  for  broad  conclusions  to  be  laid  down  as  to  their  results. 

3.  Diversion  of  the  Stream  of  Urine,  by  means  of  ureteral  implanta- 
tion into  the  loin  or  the  bowel,  is  a  confession  of  failure ;  but  almost  the 
only  hope  of  success  (p.  707). 

^Deutsche  Zeitschr.  f.  Chir.,  1900,  Iv,  50. 
» Centralbl.  f.  Chir.,  1899,  xxvi,  473. 


CHAPTER   LXXIX 
OPERATIONS  UPON  THE  SCROTUM  AND  ITS  CONTENTS 

Antiseptic  Preparation. — The  skin  of  the  scrotum  is  so  sensitive 
that  preoperative  cleansing  must  practically  be  confined  to  a  soap  and 
water  washing  a  few  hours  before  operation.  This  should  be  repeated 
when  the  patient  is  on  the  table  and  the  scrotum  flushed  finally  with 
50  per  cent  alcohol.  Tincture  of  iodin  is  totally  unreliable  as  an  anti- 
septic because  it  does  not  reach  well  into  the  crevices  of  the  corrugated 
skin. 

Local  Anesthesia.- — All  the  operations  upon  the  scrotum  may  be 
performed  under  local  anesthesia,  but  I  prefer  not  to  employ  this  ex- 
cept for  conditions  exclusively  confined  to  the  scrotum  and  not  in- 
volving any  considerable  inflammation. 

The  spermatic  cord  must  first  be  anesthetized  within  the  inguinal 
canal.  If  the  external  ring  is  large,  the  finger  may  be  introduced  into 
this  and  the  hypodermic  needle  thrust  first  through  the  skin,  then 
through  the  external  oblique  and  then  into  the  tissues  of  the  cord  where 
some  30  c.c.  of  0.25  per  cent  solution  of  novocain  is  injected.  If  the 
finger  cannot  be  introduced  into  the  external  ring,  the  accuracy  of  the 
procedure  depends  upon  the  surgeon's  sense  of  touch,  which  will  tell 
him  when  his  needle  pierces  the  external  oblique  over  the  inguinal  canal. 
While  awaiting  the  action  of  this  anesthesia,  the  skin  of  the  scrotum 
over  the  line  of  projected  incision  is  infiltrated. 

Postoperative  Dressing — In  spite  of  the  most  careful  hemostasis 
considerable  edema  will  occur  in  the  scrotum  after  operation,  just  as  it 
would  about  the  eyelid,  unless  some  pressure  is  provided.  It  is  for  this 
reason  that  the  operative  incision  is  usually  made  in  the  groin,  and 
for  minor  operations  not  involving  much  dissection  the  bandage  de- 
scribed for  the  treatment  of  acute  epididymitis  is  quite  sufficient  pres- 
sure and  support  (if  one  remembers  not  to  stuff  it  too  full  of  gauze). 

For  the  more  extensive  operations  involving  considerable  dissec- 
tion an  adhesive  plaster  dressing  should  be  applied,  the  bandage  be- 
ing made  of  strips  about  two  inches  wide  extending  alternately  in  each 
groin  from  the  perineum  below  to  the  abdomen  above ;  each  bandage 
overlapping. the  last,  beginning  at  the  median  line.  Provision  is  made 
for  the  penis  to  protrude  and  several  strips  across  the  abdomen  hold 
the  bandage  down.     It  can  further  be  supported  by  a  gauze  bandage 

775 


776      OPERATIONS  UPON  THE  SCROTUM  AND  ITS  CONTENTS 

over  all.     Sucli  strapping,  if  it  includes  very  little  gauze  over  tlie  in- 
cision, makes  a  very  snug  dressing. 


OPERATIONS  UPON  THE  SCROTUM 

Inflammatory,  fistulous,  and  gangrenous  affections  of  the  scrotum 
require  bold,  free  incision  and  excision.  Tlie  surgeon  should  not  have 
any  misgivings  as  to  the  length  or  variety  of  his  incisions,  since  these 
close  with  incredible  rapidity.  Even  though  the  testicles  are  laid  en- 
tirely bare  by  excision  of  gangrenous  areas  of  skin,  secondary  skin- 
grafting  is  rarely  necessary. 

Resection  of  the  uninflamed  scrotum,  which  may  be  required  for 
cosmetic  purposes  after  the  removal  of  large  tumors,  hydroceles,  or  vari- 
coceles, is,  generally  speaking,  best  performed  by  transverse  excision  of 
the  skin.  The  redundant  portions  of  the  scrotum  are  caught  with  a 
long,  curved  intestinal  clamp,  and  the  skin  protruding  below  the  clamp 
cut  away.  The  incision  may  then  be  closed  by  suture  before  removal 
of  the  clamp,  though  hemostasis  is  more  likely  to  be  effectively  accom- 
plished if  the  clamp  is  first  removed,  the  bleeding  points  in  the  fascia 
caught  and  tied,  and  the  skin  then  sutured. 


VASOTOMY 

The  vas  deferens  is  identified  by  grasping  the  tissues  of  the  sper- 
matic cord  between  the  thumb  and  index  finger  and  permitting  them  to 
slip  to  and  fro  from  the  grasp  until  the  thick,  cordlike  vas  is  distinctly 
appreciated.  This  is  usually  to  the  inner  side  of  most  of  the  other 
structures.  The  scrotum  is  then  thrown  forward  and  the  vas  readily 
brought  under  the  skin  posteriorly.  The  point  at  which  the  vas  shall 
be  most  readily  accessible  having  thus  been  identified,  it  is  dropped  and 
this  point  is  anesthetized  by  infiltration  for  about  2  cm.  The  vas  is 
then  brought  back  under  the  infiltrated  area  and  pressed  against  it. 
The  skin  and  underlying  tissues  are  divided  and  the  vas  brought  into 
the  wound,  where  it  may  be  tied  or  opened,  or  a  piece  of  it  excised.  The 
small  skin-wound  is  then  closed  by  suture,  care  being  taken  to  include 
all  bleeding  points. 

Belfield's  operation  for  drainage  of  the  vas  deferens  and  irrigation 
of  its  ampulla  is  performed  in  a  similar  manner;  but  when  the  vas  is 
divided  a  fine  silk  suture  is  passed  into  the  wall  and  out  through  the 
lumen  of  the  upper  segment,  then  in  from  the  lumen  and  out  through 
the  wall  of  the  lower  seg-ment.  This  suture  is  tied  loosely,  and  after  the 
irrigations  have  been  performed  to  the  satisfaction  of  the  operator,  it 


OPERATIONS  FOR  VARICOCELE  777 

is  tied  tightly  in  the  hope  that  the  vas  may  reunite  patent.  Such  re- 
union would  seem  improbable,  yet  it  has  been  verified  in  several  cases. 
The  '"'unilateral  sterility"  which  is  likely  to  result  from  this  operation 
is  its  chief  objection. 


OPERATIONS  FOR  VARICOCELE 

Subcutaneous  Ligation — The  surgeon  grasps  the  scrotum  with  the 
thumb  and  index  finger  of  his  left  hand.  By  drawing  the  fingers  slowly 
toward  the  patient's  right  side  the  spermatic  cord  is  allowed  to  slip  piece- 
meal from  the  grasp.  First  the  flabby  veins  of  the  plexus  slip  through  in 
a  wormlike  bundle,  then,  after  a  slight  interval,  the  solitary  thick  vas, 
followed  perhaps  by  one  or  two  more  veins.  This  maneuver  is  repeated 
once  or  twice  until  the  surgeon  is  absolutely  sure  that  he  has  identified 
the  interval  between  the  vas  and  the  plexus.  Then,  holding  the  veins 
well  to  the  outer  side,  and  pinching  the  scrotum  tightly  to  be  sure 
that  no  veins  elude  his  grasp,  a  needle  threaded  with  a  long  strand  of 
braided  silk,  so  stout  that  the  surgeon  cannot  hreaJc  it,  is  plunged  into 
the  anesthetized  area  close  to  the  tip  of  the  thumb.  If  the  skin  in  front 
and  behind  has  been  anesthetized  this  maneuver  is  quite  painless.  When 
the  needle  emerges  from  the  back  of  the  scrotum  one  end  of  the  silk 
is  pulled  through  and  out  of  the  scrotum  posteriorly. 

The  veins  are  then  permitted  to  drop  away,  the  needle  reinserted 
through  the  posterior  puncture,  passed  forward  between  veins  and 
dartos  externally,  and  drawn  out  through  the  original  anterior  punc- 
ture.-^ 

A  little  piece  of  dartos  will  always  be  included  in  the  silk  at  the 
point  of  posterior  puncture.  This  is  torn  away  by  pulling  the  scrotum 
backward  while  making  strong  traction  upon  the  loop  of  silk.  The 
veins  are  thus  caught  in  a  loop  of  silk,  which  is  tied  firmly  and  tightly 
in  a  triple  knot.  The  ends  are  cut  short  and  the  knot  permitted  to  recede 
into  the  scrotum.  A  drop  of  collodion  upon  each  puncture  completes 
the  operation. 

This  single  ligature  suflices  for  most  cases.  I  also  often  tie  the  veins 
just  above  and,  exceptionally,  below  the  testis,  and,  in  a  few  cases,  1 
have  applied  the  ligature  to  dilated  veins  on  the  inner  as  well  as  on  the 
outer  side  of  the  vas.  I  have  never  introduced  more  than  three  liga- 
tures in  any  one  case.  The  veins  below  the  testicle  are  especially  hard 
to  separate  from  that  gland. 

For  after-treatment  the  patient  is  kept  in  bed  with  the  testicle  sup- 
ported for  forty-eight  hours.     The  pain  is  insignificant  and  may  be 

'This  teehnic  is  simpler  than  that  involving  the  use  of  the  Keverdin  needle, 
aa  originally  proposed  by  my  father. 


778      OPERATIONS  UPON  THE  SCROTUM  AND  ITS  CONTENTS 

soothed  by  a  hot-water  bag.  A  certain  amount  of  edema  persists  for 
a  month,  during  which  time  perfect  comfort  is  insured  by  a  sus- 
pensory bandage.  After  this  edema  disappears  the  ligature  may  be 
distinctly  felt,  and  usually  remains  unabsorbed  for  years.  I  have  found 
it  in  place  six  and  seven  years  after  the  operation.  Karely  the  ligature 
works  its  way  out  at  the  end  of  several  months.  This  does  not  in- 
capacitate the  patient,  since  it  is  accompanied  by  no  active  suppuration. 
To  insure  the  success  of  this  little  operation  several  points  must  be 
insisted  upon: 

1.  Cleanliness,  to  prevent  suppuration. 

2.  Careful  exclusion  of  the  vas  deferens  from  the  ligatures. 

3.  Careful  inclusion  of  all  the  varicose  veins.  If  all  are  not  in- 
cluded the  varicocele  may  not  be  cured,  or  a  vein  may  be  punctured. 

4.  Tying  the  first  knot  tightly.  If  the  first  knot  is  not  tied  with 
all  the  surgeon's  strength  he  cannot  feel  assured  that  all  the  veins  are 
obliterated. 

5.  The  use  of  very  heavy  silk. 

If  precautions  3,  4,  and  5  are  observed  there  can  be  no  recurrence 
so  long  as  nonabsorbable  ligatures  are  employed.  With  catgut  relapse 
is  certain,  with  silk  practically  impossible. 

The  Open  Operation. — It  is  best  to  make  the  incision  where  the 
scrotum  joins  the  groin,  so  that  the  veins  are  exposed  just  below  the 
external  inguinal  ring„  By  operating  in  this  region  the  danger  of 
scrotal  hematoma  is  materially  lessened  and  the  veins  are  encountered 
above  their  point  of  varicosity  and  tortuosity  and  can  be  conveniently 
handled.  The  vas,  with  its  accompanying  vessels,  is  separated  from  the 
bundle  of  veins  and  drawn  to  one  side.  The  veins  are  then  divided  be- 
tween two  ligatures,  or  else  the  bundle  of  veins  is  drawn  up  out  of  the 
scrotum,  an  inch  or  so  excised  between  ligatures,  and  the  ends  of  the 
ligatures  left  long  and  tied  together.  By  this  means  the  cord  is  short- 
ened and  the  testicle  hoisted  to  its  proper  position  alongside  of  its 
partner.     Oozing  is  then  checked  and  the  wound  closed. 

Resection  of  the  Scrotum. — This  operation  is  described  on  p.  776. 

The  distensible  scrotal  skin  cannot  be  depended  upon  to  support  the 
testicle  so  as  to  cure  varicocele,  and  therefore  I  see  no  purpose  in  reef- 
ing the  scrotum,  except  to  remove  redundant  tissue.  To  elevate  the 
testicle  the  veins  must  be  shortened. 


OPERATIONS  FOR  HYDROCELE 

Tapping.— This  requires  no  anesthetic.  The  skin  is  made  tense,  and 
a  trocar  or  large  needle  plunged  into  the  anterior  part  of  the  tumor,  a 
little  below  the  center.     The  testicle  is  thus  avoided  (Fig.  188). 


OPERATIONS  FOR  HYDROCELE 


779 


its 
the 
the 


If  the  testicle  is  wounded,  the  patient  complains  of  some  pain  and 
the  serum  withdrawn  is  bloody.  This  accident  results  in  immediate 
refilling  of  the  hydrocele  with  blood ;  but  uo  other  complication  need  be 
feared.  If  several  months  elapse  before  the  hydrocele  is  tapped  again, 
the  fluid  will  usually  be  found  limpid  and  straw-colored,  the  blood  pig- 
ment having  been  resorbed. 

Injection — The  only  instruments  required  are  an  aspirator  with  a 
large  needle,  a  hypodermic  syringe  and  needle,  and  some  pure  carbolic 
acid.^ 

The  hypodermic  needle,  detached  from  its  syringe,  is  first  plunged 
into  the  anterior  sur- 
face of  the  hydrocele 
and     watched     until 
the  appearance  of  a 
drop    of    serum    an- 
nounces    that 
point    is    within 
cavity.      Then 
aspirating    needle    is 
introduced    and    the 
fluid     exhausted,     if 
possible,   to   the   last 
drop,    since    every 
drop    of    serum    re- 
maining dilutes  the  acid  to  be  injected.     (Relapses  are  said  to  be  less 
common  if  one  irrigates  the  cavity  with  salt  solution.") 

Meanwhile,  the  hypodermic  needle  has  not  been  disturbed.  It  is 
now  screwed  to  its  syringe,  filled  with  pure  carbolic  acid,  and  0.5  to  1.5 
c.c.  (5  to  20  minims)  injected  into  the  sac.  This  is  smartly  rubbed 
for  a  moment,  and  the  skin  douched  with  alcohol  if  any  acid  has 
touched  it. 

The  subsequent  pain  is  momentary.  The  operation  requires  no 
anesthetic. 

The  patient  usually  prefers  to  remain  in  bed  for  one  or  two  days 
after  the  operation,  though  this  is  not  necessary.  For  a  week  or  ten 
days  the  sac  gradually  refills.  Then  it  should  begin  to  grow  smaller. 
If  it  is  excessively  large  at  the  end  of  a  week,  or  if  marked  resorption 
is  not  apparent  in  ten  to  fourteen  days,  a  secondary  aspiration  should 
be  performed  without  injection. 

The  advantages  of  injection  over  any  form  of  incision  are  manifest 
if  only  success  may  be  anticipated.  The  failures  so  frequently  reported 
are  due  to  three  causes — viz. : 

^  I  employ  the  crystals,  deliquesced  by  heat. 
-Herbst,  Jour.  A.  M.  A.,  1914,  Ixiii,  2219. 


Fig.  188. — Tapping  for  Hydrocele.     (Bryant.) 


780      OPERATIONS  UPON  THE  SCROTUM  AND  ITS  CONTENTS 

1.  Application  of  injection  to  cases  incurable  bv  this  method — i.  e. : 

a.  Most  symptomatic  hydroceles. 

&.  Spermatoceles,  hematoceles  and  chyloceles. 

c.  Hydroceles  with  inflamed,  indurated,  or  calcareous  walls. 

d.  Hydroceles  containing  more  than  150  c.c.   (5  ounces). 

2.  Errors  of  technic,  notably : 

a.  Incomplete  evacuation.     This  is  the  most  frequent  cause 

of  failure.     To  insure  success  the  last  drop  must  be 

squeezed  from  -ihe  vaginalis. 
h.  Injection  of  the  carbolic  acid  into  the  cellular  tissue.     One 

need  scarcely  insist  upon  this  point. 
c.  Failure   to   perform  the   secondary   aspiration,   which   is 

sometimes  part  of  the  cur^. 

3.  The  use  of  iodin  instead  of  carbolic  acid.  The  iodin  injection  is 
painful  and  uncertain,  while  the  carbolic  acid,  being  a  local  anesthetic, 
produces  only  a  momentary  tingling  and,  at  my  hands,  has  been  a  cer- 
tain cure. 

Incision  (VolJcmanns  Operation). — The  sac  is  incised  and  its  cut 
edges  sutured  to  the  skin.  The  surface  of  the  sac  is  swabbed  with  pure 
carbolic  acid  and  drained.  The  healing  of  the  wound  requires  an  in- 
terminable time,  and  the  operation  has  been  dropped  in  favor  of — 

Excision  (Bergmanns  Operation). — The  skin  and  fascia  are  di- 
vided down  to  the  surface  of  the  tunica  vaginalis  and  dissected  back 
from  it.  The  sac  is  then  opened^  its  contents  allowed  to  drain  away  and 
the  entire  parietal  layer  snipped  off.  Complete  dissection  of  the  parietal 
layer  is  a  tedious  procedure,  and  yet  recurrence  has  followed  the  opera- 
tion on  account  of  inattention  to  this  detail.  A  simpler  operation,, 
therefore,   is — 

Eversion  of  the  Sac  (WincJcelmans  Operation). — The  sac  is  bared 
and  opened  as  in  BergTuann's  operation,  and  all  the  parietal  layer  of 
the  vaginalis  that  can  be  readily  freed  is  excised.  The  testicle  is  then 
completely  extruded  from  the  scrotum,  and  the  tunica,  thus  turned  in- 
side out,  is  held  so  by  a  few  sutures  passed  behind  the  testis.  The 
cavity  of  the  vaginalis  having  thus  been  obliterated  beyond  peradven- 
ture,  the  testicle  is  replaced  and  the  wound  closed.  Unless  traumatic 
orchitis  ensues  the  cure  should  be  complete  within  ten  days. 

Andrews's  modification  of  this  procedure  consists  in  making  a  small 
incision  at  the  top  of  the  sac  and  turning  the  testis  out  through  this, 
leaving  the  sac  inside  out.    It  does  not  give  quite  as  satisfactory  results.^ 

Operations  for  Unusual  Hydroceles— In  operating  upon  infantile 
hydroceles,  bilocular  hydroceles,  and  hydroceles  of  the  cord,  each 
case  must  be  dealt  with  according  to  its  merits,  by  resection,  inversion, 
or  injection. 

*Lyle,   Surg.,   Gynec.   and   Obstet.,   Dec,    1912,   p.    733. 


EPIDIDYMOTOMY  781 

EXCISION  OF  SPERMATOCELE 

The  sac  is  brought  out  through  a  longitudinal  incision  in  the  scro- 
tum, and,  if  small,  excised  entire;  if  large,  it  must  be  incised,  its  con- 
tents evacuated,  and  its  wall  carefully  removed.  If  any  portion  of  the 
cyst  wall  is  permitted  to  remain,  the  spermatocele  is  likely  to  recur.  At 
the  point  of  implantation  of  the  epididymis,  the  cyst  wall  may  have  to 
be  destroyed  by  a  small  point  of  cauterization. 


EPIDIDYMOTOMY 

The  technic  to  be  followed  is  that  of  Hagner.  General  anesthesia 
is  practically  always  necessary.     I  have  only  once  operated  without. 

At  the  juncture  of  the  swollen  epididymis  and  testicle,  an  incision  6  cm. 
to  10  em.  in  length,  depending  upon  the  amount  of  enlargement,  is  made  through 
the  scrotum  down  to  the  tunica  vaginalis,  which  is  opened  at  the  juncture  of 
the  ej^ididymis  and  testicle.  After  the  serous  membi'ane  is  opened,  all  the  fluid 
is  evacuated  and  the  enlarged  epididymis  examined  through  the  wound.  The 
testicle,  with  its  adnexa,  is  delivered  from  the  tunica  vaginalis  and  enveloped 
in  warm  towels.  The  epididymis  is  then  examined  and  multiple  punctures  made 
through  its  fibroas  covering  with  a  tenotome,  especially  over  those  portions 
where  the  enlargement  and  thickening  are  greatest.  The  knife  is  carried  deep 
enough  to  penetrate  the  thickened  fibrous  capsule  and  enter  the  infiltrated 
connective  tissue.  When  the  knife  is  through  the  thickened  covering  of  the 
ei^ididymis,  a  very-  marked  lessening  of  resistance  will  be  felt.  If  pus  be  seen 
to  escape  from  any  of  the  punctures,  the  opening  is  enlarged  and  a  small  probe 
inserted  in  the  direction  from  which  the  pus  flows.  By  this  method,  I  believe 
there  is  less  .danger  of  injuring  the  tubes  of  the  epididymis  than  by  cutting 
with  the  knife.  After  the  probe  is  passed  in,  pus  will  be  evacuated  by  light 
massage  in  the  region  of  the  abscess,  and  a  fine-pointed  syringe  is  used  to 
wash  out  the  cavity  with  1 : 1,000  biehlorid  of  mercury,  followed  by  physiological 
salt  solution.  The  testicle  is  then  restored  to  its  normal  position,  and  in  every 
case  the  tunica  vaginalis  is  thoroughly  washed  with  1 : 1,000  biehlorid,  followed 
by  nonnal  salt  solution.  The  incision  of  the  tunica  vaginalis  is  lightly  closed 
with  a  running  catgi;t  suture;  a  cigarette  drain  of  gauze  is  then  laid  over 
the  incision,  the  skin  being  brought  together  with  a  subcutaneous  silver  wire 
suture,  the  cigarette  drain  passing  out  at  the  lower  angle -of  the  wound  (Hagner). 

The  drain  is  removed  on  the  second  day  and  the  patient  kept  in  bed 
for  from  three  to  five  days  thereafter. 

If  the  abscess  in  the  epididymis  is  large,  it  may  be  opened  by  a 
simple  puncture  through  the  adherent  skin,  but,  unless  fluctuation 
can  be  distinctly  felt,  it  is  difficult,  by  this  blind  operation,  to  strike  the 
central  suppurating  point. 


782      OPERATIONS  UPON  THE  SCROTUM  AND  ITS  CONTENTS 

EPIDIDYMOVASOSTOMY 

Anastomosis  of  the  vas  deferens  to  the  epididymis  is  described  as 
follows  by  its  author,  Dr.  Edward  Martin: 

Before  the  operation  is  undertaken,  strictures,  posturethral  lesions,  and 
chronic  inflammation  of  the  seminal  vesicles  and  vas  should  be  cured.  The 
patency  of  the  vas  from  the  epididymis  to  the  prostatic  urethra  should  be 
assured  by  an  injection  into  the  lumen  of  the  vas  of  a  watery  emulsion  of 
inert  pigment  which,  when  passed  with  the  urine  or  expressed  by  massage  of 
the  vasal  ampulla,  readily  may  be  recognized.  This  preliminary  operation  may 
be  accomplished  under  local  anesthesia  by  means  of  either  an  ordinary  hy- 
podermic syringe,  the  needle  of  which  is  blunt,  or  the  syringe  used  by  oculists 
for  washing  out  the  lacrymal  duct.  The  vas  is  held  just  beneath  the  skin  by 
the  fingers  of  an  assistant;  the  line  of  incision  is  infiltrated;  the  vas  is  exposed, 
slit  longitudinally,  and  from  20  to  30  drops  of  the  injection  are  driven  in.  A 
large  injection  is  likely  to  occasion  severe  pain  at  the  base  of  the  bladder 
(Belfield).  If  the  pigment  does  not  appear  either  in  the  urine,  in  the  seminal 
discharge,  or  as  the  result  of  massage,  anastomosis  between  the  vas  and  epididy- 
mis will  be  futile. 

I  believe  it  better  to  cut  the  vas  obliquely,  split  it  upward  for  a  quarter 
of  an  inch  and  sew  this  wide-stretched  lumen  to  the  opening  made,  either  in 
the  epididymis,  or,  if  spermatozoa  are  not  found  there,  in  '.;he  testicle.  The 
microscopist  should  be  at  hand  who  examines  the  fluid  which  exudes  from  the 
epididymis  when  it  is  opened.  This  opening  is  made  by  the  pinching  up  of  a 
very  small  portion  of  it  in  a  pair  of  conjunctival  rat-toothed  forceps  and 
snipping  this  portion  off:  by  a  pair  of  eye  scissors  curved  on  the  flat.  Usually 
a  little  blood  and  yellowish  fluid  will  exude.  This,  taken  up  on  a  cover  glass, 
will  show  innumerable  spermatozoa.  If  spermatozoa  are  not  present,  other 
openings  must  be  made  into  the  epididymis  or  testicle  until  speraiatozoa  are 
found.  The  anastomosis  between  the  cut  ends  of  the  vas  and  epididymis  may 
be  made  by  means  of  four  sutures  carried  by  fine  curved  eye-needles.  Either 
silk  or  fine  silver  wires  answer  well.  The  suture  is  carried  from  without  into 
the  wall  of  the  vas,  and  from  within  out  of  the  wall  of  the  epididymis.  The 
tying  down  of  the  sutures  completes  the  anastomosis.  The  approach  to  the 
epididymis  and  vas  is  made  through  the  posterior  scrotal  wall.  It  usually  does 
not  require  the  application  of  a  single  ligature.  The  veins  should  be  carefully 
avoided;   otherwise  troublesome  and  painful  thrombosis  will  develop. 

Bernart/  having  had  several  failures  by  the  above  technic,  had  eight 
successive  successes  as  a  result  of  introducing  a  silver  wire  into  the 
lumen  of  the  vas,  bending  it  -n_-shape  into  the  incision  in  the  epi- 
didymis, and  carrying  its  extremity  out  through  the  skin  incision. 
He  withdraws  the  wire  after  twenty-four  hours. 

^N.  r.  Med.  Jour.,  Oct.  23,  1915. 


ORCHIDECTOMY  783 


EPIDIDYMECTOMY 

The  skin  incision  in  the  scrotum  after  circumscribing  any  fistulae 
that  may  exist  is  carried  up  over  the  anterior  surface  of  the  testicle  and 
the  tunica  vaginalis  opened.  This  will  be  found  full  of  fluid  or  ad- 
herent. The  outline  of  the  epididymis  is  studied,  the  testicle  palpated 
for  masses  of  inflammation  in  this.  If  any  considerable  portion  of  the 
testicle  is  invaded  it  may  seem  wiser  to  perform  orchidectomy. 

The  one  delicate  point  in  the  operation  is  the  avoidance  of  the  vas- 
cular supply  of  uie  testicle  which  passes  close  to  the  inkier  side  of  the 
epididymis  and  may  be  involved  in  the  infiltration  about  the  globus 
major.  Therefore  in  removing  the  epididymis  one  keeps  very  close 
to  its  inner  side,  especially  near  its  head.  The  artery  of  the  vas  is 
inevitably  divided.  If  necessary,  part  of  the  tunica  albuginea  is  cut 
away  with  the  epididymis  and  subsequently  sutured  with  fine  chromic 
gut.  Doubtful  indurated  lesions  in  the  testicle  may  be  neglected.  Even 
if  they  are  tuberculous  this  will  take  care  of  itself.  After  the  whole 
epididymis  has  been  freed  with  the  adjoining  portions  of  the  vas  this 
duct  is  cut  ;md  clamped  and  freed  up  into  the  upper  part  of  the  scrotum. 

Cabot's  technic  is  probably  the  most  satisfactory  for  disposing  of 
the  vaSo  He  passes  the  clamp  on  the  lower  end  of  the  vas  up  into  the 
inguinr''.  canal  imtil  it  reaches  the  region  of  the  internal  inguinal  ring ; 
there  it  is  pushed  upward  and  outward  and  the  skin  and  superficial 
tissues  incised  over  it.  The  vas  is  then  picked  up  and,  by  means  of  a 
finger,  inserted  into  the  inguinal  canal,  freed  into  the  pelvis  as  far  as 
possible,  where  it  is  clamped,  divided,  cauterized  with  carbolic  acid  and 
dropped  back.  The  groin  wound  is  closed  tight,  the  scrotal  wound  is 
drained,  and  an  adhesive  plaster  bandage  applied. 


ORCHIDECTOMY 

Removal  of  the  testicle  is  one  of  the  simplest  operations  in  the 
scrotum.  It  may  almost  always  be  performed  under  local  anesthesia, 
and  through  an  incision  at  the  junction  of  the  scrotum  and  groin.  The 
operation  is  begun  as  though  for  varicocele,  the  spermatic  cords  picked 
up,  the  vein  and  the  vas  ligatured  separately,  the  testicle  pulled  out  of 
its  fascial  bed  in  the  scrotum,  freed  by  a  few  strokes  of  the  finger,  its 
gubernaculum  tied  ofl^,  and  the  testicle  removed.  It  is  wise  to  insert  a 
small  counterdrain  of  rubber  tissue  at  the  bottom  of  the  scrotum. 

For  Tuberculosis. — The  vas  should  be  treated  as  described  in  the 
preceding  section. 

For  Tumor — If  the  veins  are  infiltrated  or  there  are  any  signs  of 


784      OPERATIONS  UPON  THE  SCROTUM  AND  ITS  CONTENTS 

intra-abdominal  metastasis  no  search  for  glands  in  the  abdomen  should 
be  made.  But  if  the  disease  seems  strictly  localized  the  incision  should 
be  carried  upward  and  outward  parallel  to  the  fibers  of  the  external 
oblique  to  the  tip  of  the  eleventh  rib  or  thereabouts  (Bland-Sutton 
advises  a  vertical  incision  along  the  outer  border  of  the  rectus  muscle). 
Through  this  incision  the  peritoneum  is  stripped  forward  until  the 
spermatic  vessels  are  identified  running  up  from  the  inguinal  canal; 
these  are  excised  and  the  region  internal  to  them  and  adjacent  to  the 
great  vessels  inspected  and  palpated  for  enlarged  glands.  These  are 
removed  in  one  mass  with  as  much  of  the  retroperitoneal  fat  as  can  be 
conveniently  taken  awav.  The  glands  will  be  found  along  the  lumbar 
region  and  perhaps  one  gland  at  the  iliac  bifurcation. 


OPERATION  FOR  CRYPTORCHIDISM 

An  oblique  inguinal  incision  is  made  as  for  the  operation  of  hernia. 

Regardless  of  whether  the  testicle  is  inside  or  outside  of  the 
canal  the  incision  is  carried  to  the  external  oblique  which  is  exposed 
down  to  the  external  ing-uinal  ring  and  opened  as  for  hernia. 

The  spermatic  cord  or  hernial  sac  is  then  exposed  by  division  of 
the  fibers  of  the  cremaster  and  lifted  out  of  its  bed.  If  the  testicle  lies 
in  the  inguinal  canal  or  on  the  pubic  bone  its  gTibernaculum  is  clamped 
and  cut  and  the  rest  of  its  attachments  freed  by  blunt  dissection.  (If 
the  testicle  lies  within  the  abdomen  it  is  not  seen  until  after  the  hernial 
sac  is  opened.) 

If  a  hernial  sac  is  not  readily  found  this  is  carefully  looked  for 
at  the  upper  end  of  the  incision  and  when  found  is  separated  in  the 
usual  manner  from  the  spermatic  cord.  (If  the  testicle  is  in  the  ab- 
domen it  may  be  felt  within  the  internal  ring  and  pulled  out  by  traction 
on  the  g-ubernaculum. ) 

After  separation  of  the  spermatic  cord  from  the  hernial  sac  the 
testicle  is  grasped  in  a  piece  of  gauze  by  an  assistant  and  an  effort  is 
made  to  remove  all  the  fascia  and  bits  of  cremaster  from  about  the 
vessels  and  vas.  If  these  tissues  are  well  developed,  the  neatest  pro- 
cedure is  to  open  each  fascial  compartment  as  though  operating  for 
varicocele  or  vasotomy,  and  having  freed  on  the  one  hand  the  vas  with 
its  vessels,  and  on  the  other  hand  the  pampiniform  plexus,  to  separate 
these  from  their  surrounding  fascia,  to  divide  the  fascia  and  split  it 
up  over  each  vascular  bundle  thus  freeing  these  immediately  and  com- 
pletely. This  procedure  is  most  important  and  cannot  always  be  done 
in  this  neat  manner.  Picking  off  tight  bands  of  fascia  here  and  there  is 
the  best  we  can  do  in  many  instances,  and  this  process  is  not  only  slow, 
but  also  endangers  the  veins. 


OPERATION  FOR  CRYPTORCHIDISM  785 

The  testicle  will  now  be  found  to  have  been  loosened  somewhat,  but 
not  quite  sufficiently  to  permit  it  to  lie  loosely  in  the  bottom  of  the 
scrotum.  The  testicle  is  once  more  held  up  and  the  finger  passed  along 
the  vas  (and  later  the  vessels  of  the  pampiniform  plexus)  up  into  the 
abdomen  as  high  as  it  can  reach,  separating  very  gently  the  fascial 
sheath  in  which  these  structures  lie.  By  this  maneuver  a  very  consid- 
erable additional  length  can  be  obtained,  especially  of  the  veins,  and 
unless  the  testicle  was  actually  at  or  near  the  internal  abdominal  ring,  it 
will  usually  be  found  that  the  veins  can  be  readily  made  much  longer 
than  the  vas.  If  the  vas  still  seems  short  this  may  be  lengthened  by 
nicking  the  fascia  internal  to  the  internal  epigastric  vessels,  and  slip- 
ping the  testicle  into  the  abdomen  beneath  the  internal  epigastric  vessels 
and  out  again  through  the  new  hole.  If,  after  every  effort  has  been 
made,  the  pampiniform  plexus  still  remains  too  short  it  must  be  sacri- 
ficed. 

A  bed  is  now  made  in  the  scrotum  by  inserting  two  fingers  into  this, 
and  working  a  hole  down  to  the  very  skin  at  the  bottom-most  part  of 
this  sac. 

If  the  tunica  vaginalis  has  not  been  opened  and  inverted  in  the 
course  of  the  operation  this  is  now  done. 

The  scrotum  is  now  turned  inside  out  by  the  pressure  of  a  finger 
at  its  base,  and  a  chromic  catgut  suture  caught  through  the  deeper  layers 
of  the  skin  at  this  point  and  again  carried  through  the  tunica  albuginea 
of  the  testicle,  and  at  a  point  near  its  lower  pole.  Before  this  suture 
is  tied  one  observes  carefully  that  there  is  no  twist  of  the  spermatic 
cord.  The  suture  is  then  tied  tightly,  the  scrotum  pulled  downward,  and 
the  testicle  thus  placed  in  its  bottom. 

There  is  no  need  of  any  further  traction.  Sutures  to  the  thigh,  etc., 
do  not  hold  the  testicle  in  the  scrotum  unless  it  has  been  properly 
loosened  from  above,  and  if  properly  loosened  it  requires  no  stay 
suture. 

The  hernial  sac  is  then  tied  off  and  the  inguinal  canal  reconstructed 
as  in  the  operation  for  hernia  excepting  that  the  cord  is  not  transposed. 

This  operation  should  never  be  performed  on  children  younger  than 
eight  or  nine  years  of  age.  At  this  age  they  are  sometimes  rather  un- 
manageable after  operation,  and  it  may  be  well  to  place  the  child  in  a 
plaster  cast. 


CHAPTEE   LXXX 
OPERATIONS  UPON  THE  PENIS 

INCISION  OF  THE  FORESKIN  FOR  CHANCROID 

This  little  operation  is  performed  under  infiltration  anesthesia, 
particular  care  being  taken  to  anesthetize  the  mucous  membrane.  A 
grooved  director  is  then  inserted  under  the  foreskin  (not  in  the  urethra, 
if  you  please),  and  upon  this  the  skin  and  mucous  membrane  are  split 
with  scissors  from  the  free  margin  well  back  to  the  corona. 

It  is  better  practice  to  make  two  such  incisions,  one  on  each  side  of 
the  penis,  as  recommended  bv  Taylor,  rather  than  to  make  a  single 
dorsal  incision,  which  does  not  thoroughly  expose  the  pockets  on  each 
side  of  the  frenum. 

Do  not  suture,  but  apply  25  per  cent  argyrol  solution  in  the  hope 
of  preventing  cb  aneroidal  inoculation  of  the  wound. 

CIRCUMCISION 

Local  Anesthesia — The  anesthetic  solution  is  injected  in  a  circle 
around  the  penis  near  its  base,  about  one  c.c.  being  injected  on  each 
side  beneath  Buck's  fascia.  This  usually  anesthetizes  the  whole  sur- 
face, though  additional  infiltration  into  the  mucosa  near  the  corona 
may  be  required.  If  the  prepuce  cannot  be  retracted,  a  line  of  infiltra- 
tion is  made  as  far  as  possible  within  the  mucous  membrane  on  its  dorsal 
aspect.  This  is  then  split  up,  th3  skin  retracted,  and  the  circle  of 
infiltration  completed. 

During  infiltration  and  throughout  the  operation  a  band  of  gauze 
should  be  kept  tied  about  the  shaft  of  the  penis. 

The  Operation. — Catch  the  prepuce  at  its  mucocutaneous  junction 
above  and  below  with  artery  clamps,  and  draw  it  forward  as  far  as 
possible. 

Now  apply  the  circumcision  forceps  (long-bladed  straight  forceps). 
They  are  to  be  clamped  on  the  foreskin  at  an  angle  of  G0°  with  the  long 
axis  of  the  penis.  Tlie  point  of  the  forceps  should  be  just  behind  the 
lower  artery  clamp,  and  great  care  should  be  employed  not  to  include 
any  of  the  glans  penis  in  the  grasp  of  the  instrument  (Fig.  189). 

786 


AMPUTATION  OF  THE  PENIS  787 

Cut  away  the  redundant  portion  of  tlie  prepuce. 

The  forceps  are  now  removed,  and  the  skin  slips  back,  exposing  the 
connective  tissue  overlying  the  mucous  membrane  which  adheres  closely 
to  the  gians.  This  is  to  be  slit  down  to  the  corona  upon  the  dorsum, 
or  laterally,  and  trimmed  away  on  each  side  up  to  the  frenum,  leaving 
only  enough  tissue  to  hold  the  sutures.  Old  adhesions  may  be  torn  or 
cut  away. 

Ligature  all  bleeding  points. 

CatgTit  is  the  best  material  v/ith  which  to  suture  the  cut  edges.     The 

first    suture    should    be 

applied    at    the    raphe, 

then   the  others  fall 

naturally  in  place.  They 

should  be  applied  very 

close     together.       Each 

one  should  take  in  the 

least  possible  portion  of 

integument  on  the  one 

side  and  of  mucous 

membrane  on  the  other. 

rrn  -IP         11,  Fig.    189. — Method  of  Applying  Circumcision  Forceps. 

ihe  ends  oi  each  alter- 
nate suture  are  left  long. 

By  means  o±  these  long  sutures  a  thick  strip  of  gauze  is  tied  turban- 
wise  about  the  penis,  covering  the  line  of  incision.  This  ti  rban  should 
be  loose  (Fig.  190). 

This  dressing  is  well  greased  with  sterile  vaselin,  and  covered  with 
a  loose  piece  of  gauze  (to  be  removed  and  replaced  at  each  urination), 
held  in  place  by  a  loose  jockstrap. 

After-treatment. — The  patient  need  not  be  confined  to  bed. 

The  sutures  begin  to  cut  loose  within  a  week.  The  turban  is  then 
cut  away;  the  remaining  sutures  cut  out  spontaneously. 

Complications — Wound  infections  after  circumcision,  notably  by 
tuberculosis  and  syphilis,  have  attracted  the  attention  of  many  authors, 
and  have  been  illustrated  by  many  curious  cases.  But,  except  after 
ritual  circumcision,  they  are  practically  unknown  nowadays,  and  pre- 
sent no  special  features.  More  remarkable  is  the  occurrence  of 
implantation  cysts  which  has  several  times  been  noticed  after  this 
operation. 

AMPUTATION  OF  THE  PENIS 

General  anesthesia  is  necessary.  Ample  skin-flaps  (see  below)  arc 
llion  cut  and  dissected  back  a  full  inch.  From  this  skin  incision  a 
Y-shaped  incision  is  carried  up  the  dorsum  of  the  penis  and  out  over 


788 


OPERATIONS  UPON  THE  PENIS 


both  groins.     Through  this  the  dorsal  veins  and  lymphatics  are  excised 
and  with  them  the  groin  glands  down  to  the  saphenous  openings. 

Then  the  knife  is  inserted  between  the  corpus  spongiosum  and  the 
and   these   bodies    separated   and   amputated,    the 

This  step  will  be  fol- 
corpora   cavernosa.      This  is 


corpora   cavernosa 
former  being  left 


cm. 


longer  than  the  latter. 


lowed  by  violent 


hemorrhage 


from  the 


Fig.  190. — Dressing  After  Circumcision. 


controlled  by  suturing  the  sheaths  of  the  corpora  to  each  other  with 
chromic  gTit.  Hemostasis  having  been  thus  effected,  the  urethra  is  split 
into  two  short  flaps  and  these  sutured  with  fine  catgut  to  the  skin.  The 
wound  is  then  dressed  with  the  stump  of  the  penis  erect,  and  provision 
made  for  passage  of  the  urine. 

The  wounds  must  be  drained. 

If  the  penis  is  to  be  amputated  close  to  the  pubes  it  is  advisable  to 
make  a  small  buttonhole  in  the  perineum,  through  which  the  urethra  is 
sutured  to  the  skin. 

Flaps — A  circular  skin  incision  was  used  by  early  operators,  but 
flap  operations  are  now  in  vogue  as  giving  more  accurate  apposition  of 


the  skin  edges  and  cleaner  healing. 


Senn  and  Jacobson  both  use  long 


EXTIRPATION  OF  THE  PENIS  789 

dorsal  and  short  ventral  flaps,  Jacobson  makes  his  so  long  that  the 
urethra  is  sutured  to  a  perforation  in  its  lower  part.  Others  prefer 
lateral  flaps. 

After-treatment — If  the  flaps  are  cut  long,  erections  need  not  be 
feared.  A  light  dressing  held  snugly  in  place  bj  adhesive  plaster  should 
prevent  oozing.  Frequent  change  of  dressing  is  necessary  to  prevent 
defilement  of  the  wound  by  urine.  The  patient  should  be  examined  for 
stricture  of  the  new  meatus  some  weeks  after  healing  is  complete. 


EXTIRPATION  OF  THE  PENIS 

With  the  patient  in  the  lithotomy  position  an  incision  is  made  encir- 
cling the  penis,  dividing  the  scrotum,  and  extending  in  an  inverted  Y 
from  the  central  point  of  the  perineum  toward  each  of  the  ischial 
tuberosities.  Through  this  incision  the  perineum  is  first  dissected  so 
as  to  expose  the  urethra  and  the  corpora  cavernosa  on  each  side  of  it. 
The  bulb  is  divided  at  a  point  about  3  cm.  anterior  to  the  triangular 
ligament,  and  the  corpus  spongiosum  dissected  free  down  to  that  struc- 
ture. Between  the  two  corpora  cavernosa  this  dissection  exposes  the 
two  arteries  of  the  corpora,  and  the  dorsal  arteries  of  the  penis  as  welL 
These  four  vessels  are  ligated  and  the  corpora  cavernosa  then  cut  away 
from  the  pubic  rami.  The  perineal  wound  is  then  sutured,  the  end  of 
the  urethra  split  and  attached  to  the  skin,  the  patient's  legs  let  down 
upon  the  table,  and  the  incision  carried  up  into  each  groin.  The  glands 
are  then  excised  down  to  the  saphenous  opening  on  each  side,  and  the 
bundle  of  fat,  glands  and  penis  taken  away  in  one  piece. 

The  testicles  may  be  removed  as  well  if  the  patient  elects. 

It  is  convenient  in  suturing  the  scrotum  to  take  up  part  of  the  flaps 
by  making  a  transverse  suture  of  the  central  portion  of  the  loose  scrotal 
skin.  The  wounds  are  otherwise  closed  as  they  were  made  with  liberal 
drainage  by  rubber  tissue. 


APPENDIX 

SYPHILIS 


CHAPTEE   LXXXI 
THE  GENERAL  CHARACTERISTICS  OF  SYPHILIS 

Syphilis  (the  pox)  is  an  infectious  disease  caused  by  the  spirochaet^ 
pallida.  It  is  acquired  by  contagion  or  by  heredity;  it  is  chronic  in 
course,  indefinite  in  duration,  essentially  intermittent  in  character, 
manifesting  itself  by  a  succession  of  lesions  which  involve  the  whole 
body,  and  which  are  arbitrarily  classified  as  primary,  secondary,  ter- 
tiary, and  parasyphilitic.-^ 

Syphilis  is  as  varied  in  character  as  it  is  widespread  in  distribution. 
ISTo  country  in  the  world,  no  organ  in  the  body,  is  exempt  from  its  taint. 
It  shortens  more  lives  than  we  can  estimate,  and  its  ultimate  ravages 
are  not  yet  known. 

ACQUIRED  SYPHILIS 

The  general  characteristics  of  syphilis  are  best  studied  in  its  "ac- 
quired" form.  The  peculiarities  of  hereditary  syphilis  may  be  subse- 
quently discussed. 

The  disease  may  be  acquired  only  by  contact  with  a  syphilitic  sore 
or  with  some  substance  upon  which  the  secretion  of  a  syphilitic  lesion 
has  been  recently  deposited.  The  infection  does  not  travel  in  the  air, 
nor  do  rooms  occupied  by  syphilitics  become  infected.  Moreover,  it 
is  probably  incapable  of  piercing  the  intact  integument. 

The  Primary  Lesion. — Acquired  syphilis  always  begins,  after  a  few 
weeks'  incubation,  with  an  eroded  papule  at  the  point  of  inoculation. 
This  lesion  is  called  chancre,  and  is  accompanied  by  a  characteristic 
inflammation  in  the  adjacent  lymph  glands.  This  chancre  and  adenitis 
constitute  the  primary  lesion. 

Generalization. — With  the  appearance  of  the  positive  Wassermann 
reaction,  four  to  eight  weeks  after  the  appearance  of  the  chancre,  the 
generalization  of  the  infection  is  obviously  complete.  Indeed  generali- 
zation is  doubtless  accomplished  by  the  time  the  inguinal  glands  are 
enlarged. 

A  few  days  or  weeks  later  the  secondary  lesions  appear.     These 

consist  of  typical  exanthemata  upon  the  skin  and  mucous  membranes, 

*  The  classification  of  late  sclerotic  lesions  as  quaternary  has  been  suggested, 
but  is  not  generally  accepted. 

793 


794  THE  GENERAL  CHARACTERISTICS  OF  SYPHILIS 

acute  inflammations  of  certain  organs  (iritis,  periostitis,  meningitis, 
etc.),  and  evidences  of  general  infection.  The  toxemia  is  often  very 
light  and  generally  lasts  but  a  few  weeks,  while  the  localized  secondary 
lesions  have  a  tendency  to  relapse,  after  intervals  of  apparent  health,  for 
at  least  two  years.  These  localized  secondary  lesions  are  infectious, 
superficial,  and  benign  (i.  e.,  tending  to  spontaneous  cure,  and  gener- 
ally speaking,  not  destructive  of  tissue  nor  productive  of  a  permanent 
scar).  They  are  malignant  only  in  the  sense  that  grave  late  lesions, 
notably  those  of  the  nervous  system,  probably  develop  upon  insignificant 
early  ones. 

The  Tertiary  Lesions — The  tertiary  lesions  of  syphilis  may  occur 
at  any  time  after  the  appearance  of  the  chancre.  They  may  relapse 
after  an  interval  of  years.  They  rarely  appear  until  after  the  first 
outbreak  of  secondary  lesions  has  spent  itself.  In  contrast  to  the  sec- 
ondary lesions  they  are  clinically  not  infectious,  are  deep  rather  than 
superficial  in  location  and  malignant  in  that  they  destroy  tissue  and 
show  little  or  no  tendency  to  spontaneous  cure.  Histologically  the  ter- 
tiary lesion  is  either  a  specific  syphilitic  granuloma  (gTimma)  or  a 
difi^use  interstitial  sclerosis. 

The  Parasyphilids. — Finally,  there  is  a  class  of  lesions,  the  pathol- 
ogy of  which  does  not  at  first  sight  suggest  syphilis,  termed  by  Tournier 
the  parasyphilids.  These  lesions  occur  usually  after  the  other  syphilitic 
lesions  have  ceased  to  appear.  They  are  relatively  rebellious  to  anti- 
syphilitic  medication. 

The  exact  nature  of  the  parasyphilids  was  not  clear  until,  within 
the  last  few  years,  the  development  in  the  seropathology  of  syphilis 
has  proven  them  all  truly  specific. 

Are  There  Periods  of  Syphilis? — The  above  classification  is  an  arbi- 
trary one.  The  primary  lesion  is  definite  and  immutable  (though  it 
may  be  overlooked),  but  beyond  this  all  is  variable.  Secondary  lesions 
may  be  so  mild  as  to  pass  unnoticed.  Tertiary  lesions  may  never  occur, 
or  they  may  appear  before  the  secondary,  or  the  two  may  exist  side  by 
side  or,  more  confusing  still,  a  given  lesion  may  be  on  the  border  line, 
perhaps  secondary,  perhaps  tertiary ;  and  a  superficial  lesion,  apparently 
secondary  at  first,  may  later  develop  the  characteristics  of  tertiarism. 
Moreover,  parasyphilitic  lesions  may  co-exist  with  tertiary  manifesta- 
tions. 

Hence  there  is  no  sucJt  tiling  as  a  purely  secondary  or  tertiary  period 
of  the  disease.  Secondary  symptoms ;  yes.  Tertiary  symptoms ;  yes. 
Periods;  no.  The  terms  secondary  and  tertiary  are  conventional  sym- 
bols to  express  the  quality  of  certain  symptoms.  It  is  utterly  mislead- 
ing to  apply  them  to  periods  of  time  when  these  periods  so  overlap  as  to 
produce  confusion  from  the  use  of  terms  whose  only  purpose  is  to  pre- 
vent confusion. 


EXTRAGENITAL  AND  NON-SEXUAL  INFECTION  795 

TRANSMISSION    OF    SYPHILIS 

Experimental  investigations  upon  monkeys  have  confirmed  the  ac- 
cepted theories  of  syphilitic  infection. 

We  have  learned  that  the  spirochete  is  the  infectious  agent,  and  that 
infection  is  most  common  from  the  chancre  and  the  secondary  lesions. 
But,  inasmuch  as  rather  intimate  contact  with  the  secretions  of  a  syphil- 
itic lesion  is  essential  to  infection,  it  is  probable  that  of  the  secondary 
lesions  only  the  moist  papules  and  ulcers  are  clinically  infectious.  Dry 
secondary  lesions  and  tertiary  lesions  do  not  transmit  the  spirochete 
even  though  they  contain  it.     They  are  not  infectious. 

There  has  always  been  question,  however,  of  the  virulence  of  the 
secretions  of  the  syphilitic,  notably  his  semen,  and  also  of  the  virulence 
of  his  blood,  notably  in  reference  to  surgical  operations.  That  the 
secretions  may  be  virulent  is  proven  by  the  discovery  of  spirochete  in 
the  nares,  on  the  conjunctiva,  in  the  epithelium  of  the  bowel  and  of 
the  kidney  in  hereditary  syphilis,  while  a  monkey  has  been  infected  by 
the  apparently  normal  semen  of  a  syphilitic  man. 

Whether  in  each  of  these  instances  some  minute  syphilitic  lesion 
was  present  and  accounted  for  the  exudation  of  spirochetes  is  a  purely 
academic  question.  The  clinical  fact  remains  that  the  overwhelming 
infection  of  severe  hereditary  syphilis  may  produce  an  infectiousness 
of  all  the  apparently  normal  secretions;  while  in  acquired  syphilis  the 
apparently  normal  semen  may  be  infectious. 

That  infection  from  such  sources  must  be  rare,  however,  is  shown  by 
the  numerous  failures  of  inoculations  made  with  mothers'  milk,  with 
urine,  with  semen,  etc. ;  and  the  danger  of  such  infection  is  probably 
extremely  small  unless  from  the  prolonged  contact  possible  in  seminal 
transmission; 

The  danger  of  infection  from  syphilitic  blood  is  even  slighter.  The 
spirochetes  are  present  in  the  blood  only  in  the  most  florid  stage  of 
the  disease.  The  real  danger  of  infection  with  syphilis  lies  in  the 
mucous  ulcer  or  papule,  which  may  exist  unsuspected  and  even  undis- 
coverable  about  the  mouth  or  genitals. 

Whether,  as  has  been  alleged,  a  clean  woman  may  act  as  an  inter- 
mediary host  and  convey  the  virus  from  a  syphilitic  partner  to  a  clean 
one,  and  yet  escape  infection  herself,  would  be  hard  to  prove,  though 
such  an  accident  is  eminently  possible. 


EXTRAGENITAL  AND  NON-SEXUAL  INFECTION 

Though  syphilis  occurs  in  all  lands  and  at  all  ages,  it  is  rolntive'y 
much  more  common  in  some  countries  than  in  others.     Thus  in  .some  of 


796  THE  GENERAL  CHARACTERISTICS  OF  SYPHILIS 

the  Balkan  states  and  in  certain  parts  of  Eussia  and  Asia  Minor,  in 
many  tropical  countries,  and  in  certain  isolated  communities,  syphilis  is 
practically  endemic.  Everyone  has  the  disease,  and  it  is  transmitted 
fully  as  commonly  by  extragenital  as  by  genital  contact.  In  the  United 
States,  however,  the  disease,  though  universally  distributed,  probably 
affects  a  smaller  proportion  of  the  community  than  in  most  countries; 
and,  inasmuch  as  we  do  not  indulge  in  kissing  and  other  forms  of  per- 
sonal endearment  so  much  as  our  European  neighbors,  extragenital 
infections  are  relatively  uncommon  among  us. 

Among  some  2,200  syphilitic  men  I  found  but  70  instances  of  extra- 
genital chancre;  while  among  207  syphilitic  women,  21  showed  or  gave 
history  of  extragenital  chancre.  This  proportion — about  3.5  per  cent 
for  men  and  10  per  cent  for  women  ^ — confirms  the  accepted  belief  that 
women  are  more  often  innocently  contaminated  than  men,  while  the 
method  of  contamination  is  sufficiently  indicated  by  the  following  table, 
in  which  practically  all  chancres  of  lip,  tongue,  and  tonsil  were  due  to 
kissing,  while  almost  all  the  finger  chancres  in  men  occurred  in  doctors 
and  were  due  to  vaginal  examination,  only  one  of  them  being  attributed 
to  infection  during  a  surgical  operation.  The  breast  chancres  were  ac- 
quired by  nursing  syphilitic  infants.  A  chancre  of  tongue  or  tonsil  may 
surely  be  acquired  by  simple  lip  contact  with  an  infected  surface,  just  as 
urethral  chancre  may  result  from  normal  coitus. 

Extragenital  Chancre 

TABLE 

Male •  70  cases      Female 21  cases 

Finger    34     "               Lip    13  " 

Lip 24     "               Finger    2  " 

Tongue 4     "               Vaccination 2  " 

Tonsil 2     "               Breast 2  " 

Abdomen    2     "              Tonsil   1  case 

Cheek    1  case           Eyelid  1     *  * 

Chin 1     " 

Eyelid 1     '  < 

Arm    1     " 

Although  the  disease  may  only  be  transmitted  by  inoculation  of  the 
secretions  from  the  primary  or  secondary  lesions,  and  although,  theo- 
retically at  least,  the  possession  of  an  unbroken  integument  protects 
from  danger  of  infection  with  syphilis,  one  can  never  be  absolutely  sure 
that  a  patient  in  the  first  two  or  three  years  of  syphilis  has  not  some  in- 

^Fournier  has  tabulated  10,000  chancres  (96  per  cent  of  them  in  men),  of  which 
94  per  cent  were  genital  in  man  and  only  63  per  cent  in  women. — They  kiss  everyone 
in  France. 


SYPHILIS  AND  MARRIAGE  797 

significant  lesion  of  mouth  or  genitals  whose  presence  lie  does  not  real- 
ize, nor  can  one  be  sure  of  an  absolutely  unbroken  integTiment.  It 
cannot  be  too  often  repeated — syphilis  is  frequently  transmitted  by  a 
person  who  believes  he  has  no  lesions  of  syphilis  upon  him  to  a  person 
who  believes  his  integument  intact. 

Does  Exposure  Necessarily  Imply  Infection? — ISTo;  emphatically 
not.  The  physician  who  has  the  confidence  of  his  patients  will  occasion- 
ally come  upon  cases  where  exposure,  even  repeated  exposure,  has  not 
resulted  in  infection. 

The  following  set  of  cases  related  to  me  by  Dr.  John  F.  Connors 
may  serve  as  an  example :  Eleven  men  were  repeatedly  and  in  rotation 
exposed  to  infection  from  a  single  woman.  They  thought  themselves 
well  and  she  was  not  obviously  diseased.  Yet  6  of  them  contracted 
gonorrhea  and  chancroid,  4  syphilis  and  chancroid,  and  1  chancroid 
alone.  Total,  chancroid,  100  per  cent;  gonorrhea,  55  per  cent;  syphilis, 
36  per  cent. 

When  Does  Syphilis  Cease  to  Be  Infectious? — Since  the  probabili- 
ties are  so  vague,  what  are  the  possibilities  ?  The  question  is  by  no 
means  easy  to  answer.  Certainly  8  out  of  10  syphilitics  cease  to  be 
infectious  within  three  years.  Certainly  99  men  out  of  100  cease  to  be 
infectious  within  five  years.  Certainly  the  proportion  of  infections 
from  syphilitics  of  more  than  five  years'  standing  is  infinitesimal,  and 
if  the  patient,  at  the  end  of  the  fifth  year  of  his  disease,  has  been  two 
years  without  symptoms  or  treatment,  he  may  be  guaranteed  for  matri- 
mony, though  against  (noninfectious)  relapses  in  his  own  person  he 
may  never  be  wholly  guaranteed. 


SYPHILIS  AND  MARRIAGE 

The  danger  of  marital  infection  is  instant,  and  the  chances  for  it 
are  overwhelming  during  the  first  year  of  the  disease,  much  less  in  the 
second  year,  1  to  4  in  the  third  year,  and  all  but  nothing  after  the 
fifth  year — whether  the  patient  has  been  well  treated  or  not. 

The  syphilitic  woman  bears  syphilitic  children  for  ten  years  or  more. 
But  after  the  fifth  year  she  does  not  infect  her  husband. 

Most  practitioners  are  willing  to  assure  their  patients  that  after 
three  years  of  treatment  all  danger  of  transmitting  the  disease  is  past. 
Yet  this  is  by  no  means  an  absolute  rule.  Tarnowsky  has  reported  ^  the 
transmission  of  syphilis  in  the  fifth,  sixth,  ninth,  tenth,  and  fifteenth 
years.  ISTeumann  ^  accepts  the  possibility  of  contagion  between  the 
fifth  and  the  tenth  year,  and  perhaps  later.     Fournier  relates  3  infec- 

^  Third   Internat.    Congress    of    Dermatology,    1896. 
*  Wien  med.  Presse,  1899. 


798  THE  GENERAL  CHAEACTERISTICS  OF  SYPHILIS 

tions  during  tlie  sixth  year,  1  in  tlie  seventh,  6  in  the  eighth,  3  in  the 
ninth,  2  in  the  tenth ;  but  at  this  point  even  Fournier  falters.  He  relates 
cases  of  supposed  infection  at  the  end  of  twelve,  thirteen,  and  seven- 
teen years ;  but  confesses  that  "in  view  of  the  complexity  of  the  subject 
and  the  great  possibility  of  error  in  so  delicate  a  matter,  these  cases 
are  as  yet  too  few  to  warrant  any  conclusion  being  drawn  from  them." 

But  Fournier  is  an  extremist.  He  stands  almost  alone  in  his  horror 
of  late  infections.  Twenty  years  ago  he  acquiesced  in  matrimony  at  the 
end  of  five  years  of  syphilis;  today  he  says:  "If  my  son  contracted 
syphilis,  I  should  not  permit  him  to  marry  before  the  sixth  or  seventh 
year  of  the  disease."  ^  We  can  afford  to  be  a  little  milder  and  assert 
that  matrimony  is  often  safe  and  sometimes  justifiable  at  the  end  of 
three  years,  but  unless  the  social  elements  at  stake  are  very  great  it  is 
more  prudent  to  follow  the  rule  that  marriage  of  a  syphilitic  is  permis- 
sible only  after  five  years,  during  the  last  tivo  of  which  he  has  been  with- 
out symptoms  and  without  treatment.  The  occurrence  of  symptoms, 
especially  if  they  be  secondary  symptoms,  after  the  third  year  of  the 
disease  should  postpone  matrimony  until  two  years  have  elapsed  since 
the  termination  of  the  treatment  required  to  cure  these  symptoms. 

The  reason  for  requiring  two  years  of  health  is  this :  Late  infections, 
like  early  ones,  are  due  practically  always  to  contamination  by  sec- 
ondary lesions  in  the  mouth  and  upon  the  genitals.  Of  the  18  cases 
related  by  Fournier  in  which  infection  occurred  between  the  sixth  and 
seventeenth  years  of  the  disease,  10  were  buccal  and  8  genital  infec- 
tions. JSTow  these  lesions  are  likely  to  relapse  persistently  and  without 
long  intervals  of  health.^  Consequently,  the  lapse  of  two  years  without 
such  lesions  is  a  sufficient  guarantee  that  they  will  not  recur.  If  the 
patient  is  an  inveterate  smoker,  he  should  be  warned  of  the  danger  of 
relapsing  lesions  of  the  tongue  to  which  his  habit  subjects  him.  Curi- 
ously enough,  several  patients  had  been  repeatedly  warned  of  thi^  dan- 
ger before  they  succeeded  in  infecting  their  wives. 

A  repeatedly  negative  Wassermann  reaction  should  be  required  as 
evidence  of  continued  health. 

Finally,  let  it  be  remembered,  the  moral  aspect  of  this  question  must 
carry  fully  as  much  weight  as  the  physical.  To  prohibit  matrimony  in 
a  given  case  may  wreck  a  man's  life  even  more  completely  than  syphilis 
could  blast  his  wife's,  and  though  this  consideration  can  have  no  force 
in  the  first  two  years  of  the  disease  when  infection  is  all  but  certain,  in 
the  fourth  and  fifth  years  one  may  make  exceptions  for  adequate  social 
cause  and  with  due  precautions,  deeming  the  possibility  of  infection 
light  in  comparison  to  the  certain  despair  implied  by  delay.    After  the 

^  Bull,  de  la  soc.  franc,  de  prophylaxie  san.  et  mor.,  1906,  v.  125. 
=*  Whereas   tertiary   noncontagious   lesions   often    relapse    after   many   years   of 
health. 


HEREDITARY  SYPHILIS  799 

fiftli  year  it  is  wiser  even  to  urge  matrimony,  for  nothing  so  completely 
disarms  syphilis  of  its  terrors  as  the  possession  of  a  calm  fireside,  a 
happy  wife,  and  a  ruddy  child.  Many  a  man  has  been  driven  to  this 
happiness  like  a  whipped  cur,  and  has  found  in  it  a  fullness  of  content 
which  the  medicines  and  maxims  of  no  physician  could  provide. 


SALVARSAN  AND  INFECTIOUSNESS 

The  above  paragraphs  were  written  before  the  discovery  of  salvar- 
san.  In  how  far  are  they  modified  by  proper  modern  treatment  ? 
Doubtless  to  a  great  extent.  But  though  we  now  frequently  feel  morally 
certain  that  certain  patients  are  no  longer  infectious  after  their  first 
course  of  salvarsan,  we  may  be  equally  certain  that  infectious  lesions 
may  relapse  many  months  thereafter.  Perhaps  it  is  as  well  to  with- 
hold matrimony  for  five  years  until  we  are  a  little  more  assured  of 
what  the  future  holds. 


HEREDITARY  SYPHILIS 

A  syphilitic  father  may  beget  a  syphilitic  child  without  apparently 
infecting  the  mother;  yet  this  mother  cannot  be  infected  with  syphilis 
by  nursing  the  child  (Colles's  law),  although  the  child  will  promptly 
infect  any  other  wet-nurse.  Moreover,  the  mother  of  such  a  syphilitic 
child,  although  herself  remaining  healthy  many  years,  almost  invariably 
ultimately  breaks  out  with  tertiary  syphilis  {choc  en  retour).  Mani- 
festly, therefore,  the  mother  of  a  syphilitic  child,  even  though  she 
remain  apparently  sound,  is  syphilitic. 

The  danger  of  transmission  from  father  to  child  ceases  in  from  two 
to  five  years  if  the  father  is  properly  treated.  Under  inefficient  treat- 
ment paternal  virulence  may  last  indefinitely,  though  it  is  likely  to 
tenninate  within  five  years  in  any  case. 

The  danger  of  transmission  from  mother  to  child  does  not,  however, 
terminate  at  any  definite  time.  Some  mothers  continue  to  bear  syphi- 
litic children  for  years  after  the  disappearance  of  their  own  symptoms. 
That  such  cases  are  exceptional  does  not  lessen  their  importance. 

And  the  child  itself.  It  may  die  in  utero  and  be  expelled  as  a  fetid 
disorganized  mass.  It  may  be  born  to  live  but  a  few  days.  It  may 
reach  maturity,  bearing  in  mind  and  body  the  scars  of  its  parent's  mis- 
fortune. It  may  remain  well  many  years  only  to  fall  victim  to  an 
unsuspected  '^delayed  hereditary  syphilis."  It  may  not  be  infected. 
Freaks  of  fortune  and  effects  of  treatment  ring  every  possible  change. 
Of  twins  even,  one  may  be  bom  apparently  healthy,  the  other  syphilitic. 
But,  generally  speaking,   the   infection  lessens  with  each   succeeding- 


800  THE  GENERAL  CHARACTERISTICS  OF  SYPHILIS 

conception.  Thus,  when  a  man  in  the  infectious  stage  of  syphilis  mar- 
ries, the  first  product  of  conception  usually  dies  in  utero,  and  miscar- 
riage of  a  deformed,  macerated  fetus  ensues.  After  one  or  more  such 
mishaps  a  child  is  born,  cachectic,  perhaps  actively  syphilitic  at  birth  or 
soon  showing  evidences  of  the  disease.  Such  children  usually  die 
promptly.  Later  children  are  born  which  show  no  signs  of  the  disease 
at  first,  and  may  either  remain  well  or  show  certain  stigmata  of  syphi- 
litic heredity,  or  become  actively  syphilitic. 

Hereditary  syphilis  is  the  same  disease  as  acquired  syphilis.  But 
its  lesions  are  modified  by  the  undeveloped  condition  of  the  organism 
attacked  as  well  as  by  the  mode  of  infection.  There  cannot  be  said  to  be 
any  port  of  entry  for  the  virus  (unless  it  be  the  placenta)  ;  hence  there 
is  no  chancre,  no  primary  lesion. 

The  secondary  infectious  lesions  are  sometimes  skipped  (or  over- 
looked) in  hereditary  syphilis,  and  the  so-called  delayed  hereditary 
syphilis  is  always  tertiary  in  type. 

But  the  overshadowing  features  of  hereditary  syphilis  are  the  viru- 
lence with  which  it  overwhelms  the  infant  and  the  characteristic  devel- 
opmental deformities  it  imparts,  deformities  especially  of  the  teeth,  the 
cranium,  and  the  remainder  of  the  skeleton.  These  are  called  the 
syphilitic  dystrophies. 

The  details  of  hereditary  syphilis  are  dwelt  upon  in  Chapter  XC. 

HEREDITARY    SYPHILIS    OF    THE    THIRD    GENERATION 

In  face  of  a  general  agreement  of  authorities  as  to  principles,  and 
in  spite  of  the  divergent  interpretation  of  details,  one  must  at  least 
confess  that  hereditary  syphilis  in  the  third  generation  is  possible, 
though  it  must  be  eminently  rare.  And  one  may  add  by  way  of  pre- 
caution that  the  other  factors  in  heredity — especially  in  the  production 
of  congenital  dystrophies,  such  as  alcohol,  privation,  etc.,  whose  influ- 
ence is  so  marked  upon  syphilis  in  the  first  and  second  generation — 
must  be  important  elements,  and  are  perhaps  even  the  important  ele- 
ments in  determining  syphilitic  heredity — especially  dystrophic  hered- 
ity— in  the  third  generation. 


THE  SECOND  ATTACK  OF  SYPHILIS 

A  second  attack  of  syphilis  is  no  more  intrinsically  impossible  than 
a  second  attack  of  small-pox  or  malaria.  The  rarity  of  reinfection  is 
due  in  the  first  place  to  the  persistence  of  the  initial  infection,  and  in 
the  second  place  to  the  fact  that  most  men  who  get  well  of  their  first 
infection  do  so  at  a  time  of  life  when  they  are  not  much  exposed  to 


THE  SECOND  ATTACK  OF  SYPHILIS  801 

reinfection.  Hence  one  may  put  some  faith  in  the  rumors  from  coun- 
tries where  syphilis  is  endemic  that  the  hereditary  syphilitic  is  often 
found  to  be  reinfected  during  adult  life.  Its  rarity,  however,  is  attested 
by  the  fact  that  neither  Fournier,  Bartheleny  nor  my  father  ever  saw  a 
case.  I  have  seen  but  one;  a  patient  of  my  father  who,  having  been 
treated  and  apparently  cured  by  him  twenty-five  years  ago,  consulted 
me  with  a  perfectly  typical  picture  of  chancre,  ingTiinal  glands  and 
general  maculopapular  eruptions  and  a  positive  Wassermann  reaction, 
all  of  which  promptly  receded  under  salvarsan  treatment  combined  with 
mercury. 

But  since  the  introduction  of  salvarsan  medical  literature  has  been 
deluged  with  reports  of  alleged  reinfection  within  a  few  months  of 
an  apparent  cure  by  salvarsan.  Such  cases  have  usually  been  treated 
at  the  very  onset  before  the  appearance  of  any  subjective  secondary 
symptoms  other  than  perhaps  a  positive  Wassermann  reaction.  An  in- 
tensive course  of  salvarsan  has  resulted  in  the  disappearance  of  the 
Wassermann  reaction  and  of  the  chancre  and  glands.  Within  a  year, 
however,  the  chancre  reappears  and  a  so-called  second  attack  of  syphilis 
develops  in  the  usual  way.  It  would  indeed  be  surprising  if,  in  the 
majority  of  these  cases,  there  were  not  a  history  of  recent  sexual  exposure 
before  the  appearance  of  this  so-called  second  chancre.  But  I  happen 
to  have  seen  one  such  develop  without  any  history  of  re-exposure  and 
quite  a  number  of  similar  cases  have  been  reported.  Indeed  these  sup- 
posed reinfections  are,  in  the  majority  of  instances  at  least,  quite  com- 
parable to  the  so-called  neurorecidiv  (p.  828),  an  evidence  that  the 
spirochetes  have  been  almost  all  killed,  and  the  patient's  reaction  to 
them  absolutely  annihilated.  If  this  occurs  early  enough  in  the  primary 
stage  the  few  remaining  spirochetes  are  to  be  found  in  the  scar  of  the 
chancre  and  there  develop  again  and  produce  upon  the  unimmunized 
patient  a  new  attack  of  syphilis.  If  this  destruction  of  spirochetes 
occurs  later  in  the  disease,  the  persistent  focus  of  infection  is  likely 
to  be  somewhere  in  the  nervous  system  and  it  begins  anew  with  the 
shocking  results  known  as  neurorecidiv.^ 

It  is  an  essential  characteristic  of  the  true  reinfection  after  abortion 
of  syphilis  that  the  second  chancre  should  appear  on  a  different  spot 
from  the  first  one.^ 

^Cf.   Bermatolog.    Wochenschr.,  January    13,    1912. 
*Cf,  Paraounagian,  N.  Y.  Med.  Jour.,  Jan.  22,  1916. 


CHAPTER   LXXXII 

ETIOLOGY,  SEROLOGY,  AND  PATHOLOGY  OF  SYPHILIS 

In  May,  1905,  Schaudinn  and  Hoffmann,  while  endeavoring  to 
identify  the  cytorrhyctes  hiis  (Siegel),  one  of  the  alleged  causes  of 
syphilis,  observed  a  hitherto  undescribed  organism  in  the  secretions 
from  syphilitic  sores.  The  publication  of  their  findings  was  immedi- 
ately followed  by  confirmatory  evidence  from  all  parts  of  the  world. 
Metchnikoff  and  Roux  not  only  confirmed  the  observation,  but  called 


Fig.   191. — Spirochaeta  Pallida    (two  in   ceiiterj   and  Refringens   (three,   more  deeply 

stained).      (Hoffmann.) 


attention  to  the  fact  that  Bordet  and  Gengou  had  previously  observed 
the  microorganism  in  certain  syphilitic  secretions,  but  not  finding  it 
constantly,  had  dropped  further  investigation.  Levaditi  found  it  in 
lesions  of  congenital  syphilis.  Bertarelli,  Yolpino,  and  Bovero  were 
able  to  identify  it  in  stained  sections  of  syphilitic  organs.  Barrier  and 
Bergeron  identified  it  in  the  blood  of  syphilitic  patients,  and  innumer- 
able observers  in  every  country  have  noted  clinically  that  the  organism 
may  be  found  in  almost  every  lesion  of  early  untreated  syphilis,,  though 
most  common  in  the  most  infectious  lesions. 

Final  proof  that  the  spirochaeta  pallida  is  the  cause  of  syphilis 
was  provided  by  ISTogiichi's  cultures  and  inoculations  from  various 
syphilitic  lesions,  notably  the  spinal  cords  of  tabetics  and  brains  of 
paretics. 

802 


THE  SPIROCHAETA  PALLIDA  803 


THE  SPIROCHAETA  PALLIDA 

The  spirocliaeta  pallida  (spironema,  treponema  ^  pallidum)  is  a  mo- 
tile spiral  organism  (Fig.  191),  varying  in  length  from  4  to  14  /a,  in 
diameter  from  an  immeasurable  thinness  up  to  about  ^  /*;  it  is  cylin- 
drical, not  flattened ;  its  spirals  usually  number  from  6  to  14,  though  as 
high  as  20  and  25  have  been  counted  in  exceptionally  long  ones.  The 
length  and  depth  of  the  spirals  vary  from  1  to  1.5  /*. 

Whether  in  motion  or  at  rest,  alive  or  dead,  the  spirochaeta  pallida 
never  loses  its  spiral  shape. 

Methods  of  Staining. — Eor  the  examination  of  living  specimens  the 
darh-field  illumination  is  always  employed,  for  in  the  dark  field  the 
characteristic  shape  and  motion  of  the  spirochaeta  pallida  distinguish 
it  clearly  from  all  similar  organisms. 

The  sediment  to  be  examined  should  contain  neither  pus  nor  blood 
nor  other  microorganism.  It  is  least  likely  to  be  contaminated  if  the 
lesion  is  brushed  several  times  lightly  with  the  finger  covered  with 
several  layers  of  gauze.  This  suffices  to  remove  the  secretion  lying 
upon  the  surface  of  the  sore,  and  to  excite  a  slight  serous  exudate. 
After  about  ten  minutes  a  drop  of  this  exudate  is  picked  up  on  the 
platinum  loop  and  transferred  to  the  dark  field  microscope.  The  char- 
acteristics of  the  spirochete  as  seen  under  the  microscope  are  its  rela- 
tively gTcat  length  and  thinness,  the  sharpness  and  regularity  of  its 
spirals,  and  its  constant  movement.  It  progresses,  it  bends  from  end 
to  end,  and  it  rotates. 

The  spirochete  takes  the  ordinary  bacterial  stains  very  badly.  The 
standard  Giemsa  method  is  very  complex  as  compared  with  the  India 
ink  stain. 

The  latter  is  made  as  follows : 

A  small  drop  of  the  serum,  mixed  with  an  equal  amount  of  distilled 
water,  is  diluted  with  about  half  as  much  India  ink  and  spread  very 
thin  on  the  slide.  The  smear  must  not  be  fixed  by  heat.  It  dries  very 
rapidly.  The  spirochete  shows  as  a  white  or  translucent  body  in  the 
surrounding  black  field. 

The  spirochete  may  be  readily  identified  and  distinguished  from 
other  organisms  in  smears  taken  from  the  genitals  or  aspirated  from 
the  glands.  But  spirochete  diagnosis  made  from  material  obtained  from 
the  mouth  should  be  accepted  with  much  reserve,  unless  the  microscopist 
is  truly  skilled  in  this  branch  of  work;  for  the  spirillum  microdentium 
very  closely  resembles  the  spirochaeta  pallida. 

^  The  name  "  treponeina"  was  suggested  by  Scliaiidiim  as  more  accurately 
descriptive  of  the  exact  nature  of  the  parasite.  But  this  name  has  met  with  no 
general   favor. 


804      ETIOLOGY,  SEROLOGY,  AND  PATHOLOGY  OF  SYPHILIS 

Tissue  Stain. — The  best  is  Levaditi's  modification  of  tlie  Eamon  j 
Cajal  silver  stain.^ 

1.  Sections  are  cut  1  mm.  thick  and  hardened  in  10  per  cent  for- 
malin for  twenty-four  hours. 

2.  Wash  and  harden  in  96  per  cent  alcohol  twenty-four  hours. 

3.  Wash  a  few  minutes  in  water  until  they  sink. 

4.  Impregnate  with  silver  by  soaking  for  three  (to  five)  days  in  a 
1.5  per  cent  (to  3  per  cent)  solution  of  silver  nitrate  at  a  temperature  of 
38°  C. 

5.  Wash  rapidly  in  water  and  place  for  twenty-four  (to  forty-eight) 
hours  at  the  room  temperature  in 

Acid  pyrogallic 2  gm. ; 

Formalin 5  c.c. ; 

Aq.  destill 100  c.c. 

Distribution. — Sufficiently  expert  and  conscientious  investigation 
reveals  spirochaeta  pallida  in  fully  three-fourths  of  the  smears  taken 
from  chancres,  moist  papules,  and  mouth  lesions. 

It  was  to  be  hoped  that  aspiration  of  the  lymph  nodes  adjacent  to 
the  chancre  might  prove  a  simple  means  of  obtaining  uncontaminated 
smears  of  spirochaeta  pallida;  but,  unfortunately,  the  microorganism 
is  rare  in  the  center  of  nodes,  being  chiefly  confined  to  the  region  of 
the  periphery,  so  that  there  is  a  distinctly  less  probability  of  finding 
them  there  than  in  the  chancre  itself. 

Though  the  later  secondary  lesions  contain  fewer  spirochetes,  these 
have  been  found  as  late  as  nine  years  after  chancre  by  Sobernheim  and 
Tomasczewski. 

They  have  been  found  in  the  pus  from  a  nonsyphilitic  abscess  occur- 
ring during  the  acute  stage  of  the  disease  (Flligel),  in  the  serum  of 
blisters  raised  by  cantharides  (Levaditi  and  Petresco),  in  albuminous 
urine  (Dreyer  and  Toepel),  in  the  blood — after  many  failures,  and  only 
during  the  first  few  months  and  before  the  beginning  of  mercurial 
treatment  (Noggerath  and  Stahelin,  Schaudinn,  Richards  and  Hunt 
et  al.). 

The  search  for  sinrochetes  in  tertiary  lesions  was,  for  a  long  time, 
fruitless,  but  was  finally  crowned  with  success.  Tomasczewski,  who 
has  found  them  in  5  out  of  10  gummata  examined,  states  that  eight  to 
ten  hours  must  sometimes  be  spent  in  examining  smears  before  finding  a 
typical  spirochete. 

The  crowning  success  fell  to  ISToguchi,  who  was  able  to  demonstrate 
the  spirochete  in  paretic  brains,  thus  delivering  the  final  blow  to  the 

^  The  so-called  old  Levaditi,  in  contradistinction  to  the  new  or  pyridin  Leva- 
diti,  "which    is    quicker    but    not    so    accurate. 


EXPERIMENTAL  SYPHILIS  805 

theory  of  "parasypliilids/'  and  proving  paresis  to  be  as  fully  syphilitic 
as  any  other  lesion  of  the  disease. 

The  moist  lesions  of  early  hereditary  syphilis  swarm  with  spiro- 
chetes, and  they  have  been  found  (either  in  smears  or  in  sections)  in 
practically  all  the  organs  of  still-born  syphilitic  infants — viz.,  liver, 
lung,  spleen,  kidney,  suprarenal,  muscle,  heart,  stomach,  intestine,  mes- 
enteric glands,  gall-bladder  and  ducts,  ovary,  uterus,  prostate,  testis, 
urinary  bladder,  thymus,  tonsil,  bone,  joint,  etc.  They  are  usually  most 
numerous  in  the  liver,  lungs,  and  skin.  They  have  been  found  in  both 
fetal  and  maternal  placenta,  and  once  in  the  ingTiinal  glands  of  the  ap- 
parently healthy  mother  of  a  syphilitic  child  (Buschke  and  Fischer)  ! 
Curiously  enough,  masses  of  spirochetes  are  sometimes  found  in  and 
about  the  cr.pillaries  where  nc  tissue  change  has  taken  place. 

The  examination  of  normal  secretions — except  the  semen — is  nega- 
tive, except  in  severe  congenital  syphilis. 

Cultivation.- — All  attempts  to  grow  spirochetes  outside  of  the  living 
organism  proved  failures  until  jSTogiichi  succeeded  not  only  in  growing 
the  organism  and  transmitting  the  disease  to  animals  by  spirochetes 
several  generations  removed  from  their  human  host,  but  also  in  making 
from  his  cultures  a  vaccine,  to  which  has  been  given  the  name  of 
"luetin." 

EXPERIMENTAL  SYPHILIS 

Syphilis,  as  known  in  man — a  disease  characterized  by  an  initial 
lesion  and  subsequently  by  various  systemic  manifestations — can  be 
produced  by  inoculation  only  in  the  anthropoid  apes.  Other  animals 
can  be  inoculated  with  syphilis  and  then  show  an  initial  lesion  and 
certain  other  lesions  of  a  relatively  mild  sort.  Indeed  there  is  reason 
to  believe  from  the  results  of  animal  experimentation  that  certain 
strains  of  spirochetes  tend  to  produce  certain  types  of  lesions. 

But  the  most  important  practical  conclusion  yet  reached  from  these 
experiments  is  that  sypliilitic  secretions  cease  to  he  infectious  after 
twelve  to  tweyity-four  hours,  atid  much  sooner  {at  most  six  hours)  when 
dry.  This  explains  why  we  are  not  all  infected  by  cigars  and  why  the 
syphilitic  may  live  and  dine  with  his  family  in  absolute  safety  so  long 
as  the  cups,  forks,  and  spoons  that  enter  his  mouth  are  washed  and  dried 
before  being  used  by  anyone  else  at  the  following  meal. 

Prophylaxis. — As  soon  as  Metchnikoff  and  Roux  had  proved  to 
their  satisfaction  the  transmissibility  of  syphilis  to  monke^^s,  they 
turned  their  attention  to  its  prophylaxis.  The  results  of  their  experi- 
ments were  startling.  They  found  that  excision  of  chancre,  even  of 
commencinrj  chancre,  is  entirely  futile  as  a  preventive  or  minimizer  of 
the  subsequent  development  of  the  disease.    Cauterization  of  the  chancre 


806      ETIOLOGY,  SEROLOGY,  AND  PATHOLOGY  OF  SYPHILIS 

they  found  equally  futile.  Indeed,  wide  excision  of  the  inoculated  area 
at  any  time  later  than  eight  hours  after  inoculation  failed  to  prevent 
the  development  of  chancre'^  (confirmed  by  I^^eisser).  Moreover,  cau-^ 
terization  of  the  site  of  inoculation  (to  destroy  the  virus)  and  various 
antiseptics  availed  nothing. 

The  only  way  in  which  they  were  able  to  destroy  the  virus  after 
inoculation  was  by  applying,  within  six  hours,  a  calomel  salve  (calomel, 
20;  lanolin,  40).  So  universally  preventive  did  this  prove  that  they 
performed  a  confirmatory  inoculation  (with  monkey  controls)  upon  a 
medical  student,  inoculating  him  with  the  virulent  secretion  of  a  chancre 
and  of  a  mucous  papule,  rubbing  in  the  calomel  salve  within  one  hour,^ 
and  watching  him  long  enough  to  be  sure  that  no  sign  of  syphilis 
developed. 

Hence  we  may  infer  that  the  only  personal  prophylaxis  against  syph- 
ilitic infection  lies,  not  in  cauterization  or  excision,  but  in  inunction 
with  a  strong  mercurial  ointment  within  one  hour  ^  of  inoculation. 

Inoculation  Immunity — All  efforts  to  develop  artiiicially  either  an 
active  or  a  passive  immunity  to  syphilis  have  failed  in  man  as  well  as 
in  monkey.  Taking  as  a  starting  point  the  immunity  to  reinfection, 
which  begins  so  early  in  the  disease  (tenth  to  fourteenth  day),  and  usu- 
ally lasts  a  lifetime,  inoculation  experiments  have  been  made  with  the 
blood  serum  of  syphilitics,  with  the  juices  from  syphilitic  lesions  (fil- 
tered through  porcelain),  as  well  as  by  "passing"  the  infection  through 
several  individuals.  The  result  has  been  absolute  zero :  as  yet  "the 
only  way  to  be  immune  to  syphilis  is  to  have  it." 


THE  WASSERMANN  REACTION 

Among  the  innumerable  serological  tests  that  have  been  suggested 
for  the  diagnosis  of  syphilis,  the  Wassermann  reaction  alone  survives. 
But  two  modifications  of  the  reaction  are  worthy  of  comment. 

1.  Wassermann  originally  employed  an  antigen  derived  from  the 
liver  of  a  syphilitic  infant  for  he  believed  his  reaction  specific.  But 
experience  has  shown  that  other  antigens  give  as  accurate  results  as  the 
syphilitic  liver.  It  is  recogiiized  that  the  reaction  is  not,  strictly  speak- 
ing, specific  for  syphilis,  but  may  occur  under  various  other  conditions. 
The  antigen  commonly  employed  is  an  alcoholic  extract  of  bullock's 
heart. 

*  But  in  one  case  amputation  of  an  inoculated  ear  after  twenty-four  hours 
was  preventive,  and  the  monkey  was  subsequently  successfully  inoculated.  On  the 
other  hand  Neisser  has  transmitted  the  disease  by  inoculation  with  the  blood  of  an 
animal  still  in  the  primary  incubation   (before  the  appearance  of  a  chancre). 

^  Clinical  application  of  this  test  has,  however,  failed  to  prevent  the  appear- 
ance  of   chancre   in   three   reported  cases. 


THE  WASSERMANN  REACTION  807 

2.  The  antigen  may  be  made  much  more  delicate  by  cholesteriniza- 
tion.  The  status  of  the  cholesterinized  antigen  is  not  yet  fully  deter- 
mined. Quite  possibly  (indeed  such  is  my  own  impression)  this  antigen 
as  ordinarily  employed  is  actually  too  sensitive  and  gives  strong  positive 
reactions  in  some  patients  who  are  not  syphilitic. 

Indeed  the  fundamental  inaccuracy  of  the  Wassermann  reaction  is 
recognized  in  all  laboratories.  Those  that  use  a  cholesterinized  antigen, 
also  use  an  alcoholic  antigen  and  many,  as  a  further  control,  use  a 
lipoid  extract  of  the  bullock's  heart  which  gives  even  weaker  reactions. 

It  is  not  our  province  to  describe  the  Wassermann  reaction  nor  to 
comment  too  precisely  upon  its  results  for  these  depend  upon  the  intel- 
ligence with  which  they  are  interpreted. 

Each  clinician  must  familiarize  himself  with  the  work  of  a  given 
laboratory  and  control  its  results  by  a  great  number  of  known  non- 
syf)hilitics  (persons  with  no  evidence,  lesion  or  history  of  the  disease). 
The  reaction  should  exhibit  the  following  qualities: 

1.  Nonsyphilitic  patients  suffering  or  convalescent  from  pneumonia, 
scarlatina,  active  tuberculous  lesions,  and  patients  with  acidosis, 
whether  due  to  diabetes  or  to  other  cause  may  show  a  positive  reaction. 
So  may  patients  in  the  terminal  stages  of  carcinoma,  certain  lepers,  suf- 
ferers from  yaws,  etc. 

2.  An  unexplained  positive  Wassermann  reaction  will  be  found  in 
about  10  to  20  per  cent  of  hospital  cases  among  adults.  The  majority 
of  these  are  doubtless  syphilitics  who  have  overlooked  their  early 
lesions.  For  such  cases  the  typical  changes  in  the  spinal  fluid,  the 
absence  of  ankle  jerk,  or  even  the  history  of  a  chancroid  constitute  evi- 
dence of  syphilis.  In  private  practice  a  good  Wassermann  reaction  is 
positive  in  probably  not  more  than  1  or  2  per  cent  of  nonsyphilitic 
cases. 

3.  In  early  syphilis  the  Wassermann  reaction  becomes  positive 
sometimes  at  the  end  of  the  first  week,  practically  always  in  the  third 
or  fourth  week,  and  literally  in  100  per  cent  of  cases  between  the  eighth 
and  the  tenth  week. 

4.  Untreated  cases  of  syphilis,  notably  those  suffering  from  tabes, 
not  infrequently  show  a  negative  Wassermann  reaction  though  the  great 
majority  of  them  are  positive. 

5.  During  the  first  two  years  of  the  disease  treatment,  notably  by 
salvarsan,  may  make  the  Wassermann  remain  negative  even  after  the 
relapse  of  lesions. 

6.  If  salvarsan  has  not  been  employed  the  reaction  may  be  ex- 
pected to  be  positive  in  about  90  per  cent  of  cases  showing  active  lesions 
in  the  first  tliree  years  of  the  disease. 

7.  In  a  period  of  remission  the  Wassermann  will  usually  have  been 
made  negative  by  the  treatment  employed.     In  the  later  years  of  the 


808      ETIOLOGY,  SEROLOGY,  AND  PATHOLOGY  OF  SYPHILIS 

disease  the  Wassermann  reaction  is  likely  to  become  positive  before 
somatic  lesions  reappear. 

8.  Active  tertiary  lesions  are  accompanied  by  a  positive  Wasser- 
mann reaction  in  about  80  per  cent  of  cases. 

9.  Tabes  shows  a  positive  blood  Wassermann  reaction  with  relative 
rarity,  probably  in  not  over  one-half  of  the  cases. 

10.  The  blood  Wassermann  is  positive  in  at  least  90  per  cent  of 
paretics. 

11.  The  reaction  may  sometimes  be  made  negative  for  two  days  by 
a  few  alcoholic  drinks. 

The  Provoked  Wassermann  Reaction.— The  so-called  Herxheimer 
reaction  is  an  increase  in  the  active  skin  lesions  of  syphilis  as  the 
immediate  result  of  treatment.  Such  a  reaction  not  infrequently  fol- 
lows the  administration  of  salvarsan  for  the  cure  of  secondary  skin 
lesions. 

It  is  explained  on  the  theory  of  local  irritation  due  to  the  liberation 
of  toxins  from  the  great  number  of  spirochetes  suddenly  killed. 

The  provoked  Wassermann  reaction  is  apparently  a  similar  phe- 
nomenon.    The  reaction  is  this : 

Within  twenty-four  to  forty-eight  hours  after  an  injection  of 
salvarsan,  the  Wassermann  reaction,  which  has  previously  been  nega- 
tive, becomes  positive,  or  if  mildly  positive  it  becomes  more  so.  This 
positive  reaction  may  be  of  very  brief  duration.  It  usually  occurs  at 
the  end  of  forty-eight  hours  though  it  may  be  delayed  until  the  end  of 
a  week,  and  if  a  series  of  salvarsan  injections  are  being  given,  the 
second  or  third  injection  may  make  the  blood  become  more  positive  than 
the  first  did  (under  these  circumstances  the  injections  must  be  con- 
tinued until  the  blood  becomes  negative  if  that  is  possible).  The  pro- 
voked Wassermann  may  usually  be  obtained  in  patients  showing  lesions 
of  the  disease  but  a  negative  Wassermann  reaction  before  treatment. 
Patients  who  are  known  to  have  syphilis  or  are  suspected  of  having 
syphilis,  but  who  have  no  active  lesions,  sometimes  give  a  provoked 
Wassermann  and  sometimes  do  not.  The  prognosis  of  the  latter  class 
of  cases  is  believed  to  be  much  better  than  the  former. 


THE  LUETIN  TEST 

The  luetin  test  is  analogous  to  the  von  Pirquet  reaction  for  tuber- 
culosis. Luetin  is  a  fixed  dilution  of  killed  spirochetes.  It  is  injected 
into  the  skin  in  a  dose  of  0.05  c.c.  The  reaction  ^  usually  appears 
within  twenty-four  hours,  sometimes  later.  It  may  be  papular,  pustular 
or  torpid.     The  papule  is  large,  raised,  red,  indurated  and  usually  from. 

^Noguchi,  Jour,  of  Exp.   Med.,   1911,   xiv,   557. 


SPINAL  FLUID  TESTS  809 

.05  to  1  cm.  in  diameter.  It  appears  in  twenty-four  hours,  increases 
for  three  or  four  days,  and  then  gradually  subsides.  It  may  become 
pustular  on  the  fourth  or  fifth  day,  and  may  be  accompanied  by  slight 
fever.  The  torpid  form  produces  a  small  pustule,  after  an  interval  of  a 
week  or  two.  ISToguchi  ^  has  collected  statistics  which  show  that  the 
reaction  is  positive  in  30  per  cent  of  cases  of  primary  syphilis,  in  47 
per  cent  of  secondary  syphilis,  in  80  per  cent  of  tertiary  syphilis,  in 
70  per  cent  of  congenital  syphilis,  in  60  per  cent  of  nervous  syphilis, 
and  in  90  per  cent  of  visceral  syphilis.  He  states  that  the  luetin  reac- 
tion indicates  the  allergy  and  the  Wassermann  reaction  the  presence  of 
an  active  syphilitic  process.  The  two  reactions  usually  agree  though 
one  may  be  positive  and  the  other  negative.  He  believes  the  luetin  re- 
action more  accurate  in  chronic  tertiary  syphilis  not  in  the  nervous 
system. 

I  have  never  employed  luetin. 


SPINAL  FLUID  TESTS 

The  four  tests  made  upon  the  spinal  fluid  are : 

The  Globulin  Reaction — The  presence  of  globulin  in  the  cerebro- 
spinal fluid  means  organic  disease  in  the  nervous  system,  but  does  not 
declare  the  nature  of  that  disease.  (Certain  cases  of  cerebrospinal  syph- 
ilis show  a  negative  globulin  reaction.)  Globulin  is  the  first  reaction 
to  become  positive  on  the  appearance  of  syphilis  of  the  nervous  system 
and  the  last  to  become  negative.  IsTogTichi's  test  is  the  one  usually 
employed.  To  0.2  c.c.  of  spinal  fluid  is  added  0.5  c.c.  of  a  10  per  cent 
butyric  acid  solution  in  normal  saline  solution.  The  two  are  boiled, 
0.1  c.c.  of  a-l  per  cent  sodium  hydrate  solution  added,  and  the  mixture 
again  heated.  The  result  is  read  at  the  end  of  one-half  hour,  and  at 
the  end  of  twenty-four  hours.  The  fluid  varies  in  cloudiness  from  an 
opalescent  to  a  coarse  thick  precipitate.  An  opalescent  is  negative,  a 
heavy  precipitate  is  called  double  plus. 

Lymphocytosis — The  normal  spinal  fluid  may  contain  as  many  as 
five  cells  to  the  cubic  millimeter  (Nonne).  Syphilis  of  the  nervous 
system  almost  always  produces  an  increase  in  the  number  of  lympho- 
cytes (mononuclear  cells)  in  the  spinal  fluid.  In  chronic  cases,  such  as 
tabes,  the  increase  is  usually  not  very  great,  the  cell  count  running  from 
10  to  30  or  40.  Active  cases  and  paretics  often  show  a  very  high  cell 
count  (as  high  as  500).  Under  these  circumstances  the  spinal  fluid  is 
distinctly  cloudy. 

The  Wassermann  Reaction. — The  Wassermann  reaction  is  positive 
in  the  spinal  fluid  of  98  per  cent  of  paretics,  60  per  cent  of  tabetics, 

^N.  Y.  Med.  Jour.,  August  22,  1914,  c,  349. 


810      ETIOLOGY,  SEROLOGY,  AND  PATHOLOGY  OE  SYPHILIS 

and  about  the  same  percentage  of  cerebrospinal  syphilis.  The  Was- 
sermann  reaction  should,  like  the  blood  Wassermann,  be  performed  with 
at  least  two  or  three  different  antigens,  and  in  a  series  of  dilutions  of 
the  spinal  fluid  from  1  down  to  0.1  c.c.  Paresis  is  likely  to  give  a 
Wassermann  reaction  in  all  of  these  dilutions,  tabes  and  cerebrospinal 
syphilis  only  in  the  stronger  concentrations. 

The  Colloidal  Gold  Test. — The  reaction  ^  consists  in  mingling  in 
various  dilutions  colloidal  gold  with  the  cerebrospinal  serum.  The  test 
gives  a  fairly  suggestive  curve  in  syphilitic  cases  but  gives  absolute 
decolorization  in  the  stronger  concentrations  only  in  cases  of  paresis 
for  which  it  is  a  peculiarly  accurate  test. 

Pressure — It  is  customary  to  endeavor  to  estimate  the  pressure  at 
which  the  cerebrospinal  fluid  issues  into  the  needle.  So  many  mechan- 
ical elements  enter  into  consideration  here,  however,  that  in  most 
instances  the  results  are  quite  valueless. 

Precaution — The  amount  of  cerebrospinal  fluid  required  to  make 
all  of  the  above  tests  is  about  8  c.c.  The  cell  count  must  he  made  imme- 
diately; otherwise  the  cells  stick  to  the  bottom  and  sides  of  the  tube. 
The  other  reactions  may  be  made  at  leisure.  The  puncture  is  made 
in  the  usual  way  in  the  third  or  fourth  lumbar  space. 

It  is  essential  that  the  patient  remain  in  bed  for  at  least  forty-eight 
hours  after  a  lumbar  puncture.  The  penalty  for  infraction  of  this  rule 
is  severe  pain  in  the  head  and  back  of  the  neck  which  may  prove  totally 
debilitating  for  several  weeks. 


THE  PATHOLOGY  OF  SYPHILIS 

"The  syphilitic  process  is  essentially  a  granuloma  having  its  origin 
in  the  perivascular  lymphatic  spaces"  (Fordyce).  The  spirochetes 
appear  both  in  the  lymph  and  the  blood  and  during  the  so-called  second- 
ary incubation  period  they  spread  to  and  from  lesions  in  the  blood 
vessels  in  most  of  the  internal  organs  as  well  as  in  the  skin.  An  increase 
in  the  lymphocytes  of  the  spinal  fluid  occurs  in  from  20  to  40  cases  of 
early  secondary  syphilitics,  in  some  instances  even  before  the  appearance 
of  the  secondary  skin  eruption  (Wile).^  An  increase  in  the  polynu- 
clear  leukocytes  and  in  the  eosinophiles,  as  well  as  the  occasional  increase 
in  temperature  and  appearance  of  jaundice  and  enlargement  of  the 
f:pleen,  give  evidence  of  the  acute  systemic  character  of  the  infection. 
If  the  patient  submits  to  no  treatment  he  goes  through  an  early  outbreak 
(as  it  is  called)  of  varying  severity,  after  which  the  lesions  tend  to  dis- 
appear because  of  an  acquired  immunity.     This  immunity  is,  however, 

'Cf.    Miller,   Bull.   Johns   Hoplins   Hosp.,    1914,    xxv,    113. 
^Jour.  A.  M.  A.,  1913,  Ixiv,  1465. 


THE  PATHOLOGY  OF  SYPHILIS  811 

only  partial  and  not  sufficient  to  cure  the  disease.  Thereafter  all  is  con- 
fusion. The  lesions  may  relapse  soon  or  late,  moderately  or  severely,  in 
the  viscera,  the  nervous  system  or  the  skin.  There  is  grave  reason  to 
doubt  whether  syphilis  is  actually  curable  after  the  first  general  out- 
break has  occurred.  The  syphilitic  is  curable  in  the  sense  that  he  can 
often  get  into  a  condition  where  his  Wassermann  reaction  remains  nega- 
tive, and  he  remains  free  from  symptoms  so  long  as  he  is  not  debilitated 
by  trauma,  grave  disease,  or  alcoholic  or  other  excesses.  He  may,  more- 
over, after  the  lapse  of  time  be  absolutely  guaranteed  against  the  possi- 
bility of  transmitting  the  disease  to  wife  or  child.  But  in  his  own  person 
the  guarantee  of  cure,  even  clinical  cure,  is  never  absolute  but  depends 
upon  keeping  himself  in  good  condition. 

Lesions  of  the  Capillaries. — With  a  few  exceptions  the  lesions  of 
syphilis  may  be  classed  as  perivascular  granulomata — i.  e.,  infiltrations 
of  the  vessel  walls  and  of  the  surrounding  tissue  with  small,  round 
cells  and  plasma  cells.  The  vessels  most  commonly  affected  are  the 
capillaries. 

Syphilis  is,  therefore,  classed  (with  tuberculosis  and  leprosy) 
among  the  infectious  granulomata. 

The  congestion  and  proliferation  shows  itself  by  dilatation  of  the 
vessel  lumina,  swelling  and  proliferation  of  the  endothelium,  and  forma- 
tion of  new  capillaries. 

The  exudation  occurs  in  a  "coat-sleeve"  fashion,  surrounding  the 
inflamed  vessels  with  a  zone  of  infiltrate  many  times  the  diameter  of 
the  vessel  itself.  This  zone  gradually  merges  at  its  edge  into  the  sur- 
rounding normal  tissue.  Groups  of  capillaries  are  usually  affected  and, 
when  the  inflammation  is  at  all  marked,  the  zones  of  infiltrate  merge 
into  one  another  to  form  an  irregular  area  more  or  less  widespread. 

The  exudate  consists  of  small  round  cells  and  plasma  cells.  Here 
and  there  a  giant  cell  is  sometimes  seen.  These  giant  cells  are  neither 
constant  nor  characteristic  of  syphilis  (they  are  much  more  common  in 
tuberculosis). 

The  reaction  of  the  exudation  upon  the  capillaries  themselves  is  most 
important.     The  vessels  are  primarily — 

1.  Congested  and  proliferated,  and  secondarily — 

2.  Thrombosed,  "their  former  site  being  marked  by  solid  cords, 
groups  of  irregularly  disposed  cells  with  pale  staining  nuclei  and  giant 
cells  with  peripheral  or  central  nuclei  or  both"  (Fordyce^).  Without 
discussing  further  the  disputed  origin  of  the  giant  cells,  one  may  recog- 
nize that  many  of  them  are  due  to  this  capillary  degeneration. 

As  a  result  of  the  thrombosis  and  destruction  of  the  vessels,  the  in- 
filtrated zones  may  be  mottled,  showing  amid  the  cellular  exudate  lighter 
areas  representing  the  degenerated  capillaries.     Moreover,  when  this 

Vowr.  A.  M.  A.,  1907,  xlix,  462. 


812      ETIOLOGY,  SEROLOGY,  AND  PATHOLOGY  OF  SYPHILIS 

vascular  degeneration  is   extensive,   there   is  macroscopic  necrosis   of 
tissue  on  tlie  exposed  surface  or  in  the  center  of  the  lesion.     Hence  the 
erosion  of  chancre,  the  desquamation  of  the  syphilitic  papule,  the  ulcera- 
tion of  the  tuberculous  syphilid,  and  the  caseation  of  gumma. 
Three  types  of  cellular  exudate  may  be  distingaiished,  viz. : 

1.  The  diffuse  exudate  caused  by  an  acute,  intense  syphilitic  infec- 
tion in  a  soil  of  little  resisting  power.  This  is  seen  characteristically 
in  the  visceral  lesions  of  hereditary  syphilis.  A  whole  lobe  of  liver  or 
lung  is  infiltrated;  there  is  practically  no  tendency  to  localization  of 
the  exudate  or  to  central  degeneration  (gumma)  ;  all  the  vessels  are 
involved. 

2.  The  circumscribed,  mild,  multilocular  exudate  with  no  tendency 
to  central  degeneration,  but  with  a  marked  tendency  to  spontaneous 
resolution.  Such  are  the  ephemeral  lesions  of  secondary  acquired 
syphilis. 

3.  The  circumscribed,  grave,  malignant  lesions  of  tertiary  syphilis 
(whose  characteristics  are  shared  in  a  less  degree  b}^  the  chancre),  of 
which  the  gumma  is  the  type.  These  tertiary  or  gTimmatous  lesions 
thus  consist  in  dense  perivascular  exudates  with  central  degeneration 
(caseation)  due  to  vascular  obstruction  and  obliteration  in  the  periphery 
of  the  lesion. 

The  Pathology  of  Gumma. — The  subcutaneous  gumma  is  a  deep- 
set  syphilitic  tubercle.  At  its  onset  it  is  simply  a  syphiloma,  a  localized 
perivascular  granuloma,  set  in  the  subcutaneous  tissue.  But  its  center 
soon  breaks  down  into  a  gelatinous  or  gummy  mass  (whence  the  name 
"gumma").  This  central  gummy  mass  consists  of  necrotic  tissue  held 
together  by  a  network  of  fibrous  connective  tissue,  so  that  even  when 
the  mass  is  large  and  completely  disorganized  it  does  not  become  abso- 
lutely fluid,  but  is  kept  in  a  characteristic  semisolid  state. 

This  mass,  yellow  or  serosangiiinolent  in  aspect,  rapidly  enlarges 
and  bursts  through  the  skin.  Through  the  ulcer  thus  formed  the  gTimmy 
center  comes  away  bit  by  bit,  leaving  a  gummatous  ulcer. 

Gumma  of  the  internal  organs  (liver,  testicle,  etc.)  behaves  some- 
what differently.  It  begins  as  a  granuloma  and  undergoes  central  de- 
generation, but  it  finds  no  outlet,  and  is  limited  in  its  spread  by  the 
change  that  occurs  in  its  own  outer  layers.  Here  the  inflammatory 
exudate  changes  gradually  into  scar  tissue,  which  completely  envelops 
the  central  gummy  mass.  In  this  fully  developed  state  the  visceral 
gumma  therefore  consists  of  a  central  gT^mmy  mass,  surrounded  by  a 
dense  envelope  of  fibrous  tissue,  which  itself  is  infiltrated  and  sur- 
rounded by  plasma  and  small  round  cells.  Healing  takes  place  either 
by  absorption  or  by  encapsulation  of  the  gnmmy  mass.  The  contraction 
of  the  fibrous  tissue  leaves  a  characteristic  hard,  puckered  scar. 

The  diffuse  gumma  forms  still  another  pathologic  type,  in  which  the 


THE  PATHOLOGY  OF  SYPHILIS  813 

sypliiloma  is  spread  over  a  relatively  large  area,  undergoes  no  central 
degeneration,  and  heals  by  complete  transformation  into  scar  tissue. 

Lesions  of  the  Larger  Vessels. — Of  the  larger  vessels  the  arteries 
are  much  the  most  commonly  affected  by  syphilis,  the  veins  less  often, 
the  lymphatics  least  of  all. 

The  lesions  are  comparable  to  those  of  the  capillaries — i.  e.,  exuda- 
tion into  and  about  the  vessel  with  obliteration  and  degeneration  as  its 
terminal  stage. 

The  ''coat-sleeve"  infiltrate  is  seen  about  small  vessels;  but  this  sys- 
tematic disposition  of  the  exudate  diminishes  progTessively  in  propor- 
tion to  the  size  of  the  vessel  attacked  until,  in  the  aorta,  the  lesionfi 
are  usually  patches  distributed  over  the  circumference  of  the  artery,  but 
showing  no  definite  tendency  to  surround  it. 

The  changes  in  the  walls  of  the  larger  arteries  are  most  common  and 
have  been  best  studied  in  the  arteries  of  the  brain.  Whether  these 
changes  usually  begin  in  the  arterial  intima,  as  Heubner,  their  discov- 
erer, supposed,  or  in  the  adventitia,  as  is  now  generally  believed,  they 
spread  around  and  along  the  vessel  in  the  form  of  a  round-cell  exudate, 
usually  involving  the  adventitia  rather  more  than  the  intima,  but  in 
large  measure  sparing  the  muscular  tissue  of  the  media.  Actual  gTim- 
mata  may  occur  in  the  adventitia.  Thus  the  wall  of  the  vessel  is  thick- 
ened, its  elasticity  lessened,  its  intima  congested  and  roughened.  Hence 
in  the  smaller  arteries  the  clinical  result  of  syphilitic  inflammation  is 
usually  thrombosis  or  obliteration,  less  often  rupture  or  aneurysm,  while 
in  the  aorta  aneurysm  is  the  usual  clinical  manifestation  of  the 
disease.^ 

^Symmers  and  Wallace,  Jour.  A.  M.  A.,  1916,  Ixvi,  397. 


CHAPTEE    LXXXIII 

THE  COURSE  OF  SYPHILIS 

THE  ONSET 

Although  utterly  irregular  in  its  course,  syphilis  is  practically 
always  quite  characteristic  in  its  beginnings  (at  least  in  the  male), 
and  thus  the  diagnosis  of  syphilis  is  happily  most  readily  made  at  the 
time  when  it  is  most  necessary  to  make  it. 

Onset  in  Man — Let  us  take,  for  example,  a  typical  case  in  a  man. 
He  has  intercourse  on  a  given  date  (and  may  notice  an  abrasion  upon 
the  penis,  or  there  may  come  out  within  the  next  few  days  a  crop  of  her- 
petic vesicles.  Yet  in  the  great  majority  of  instances  neither  of  these 
things  is  noted).  He  thinks  himself  entirely  normal  and  notices  noth- 
ing wrong  for  a  period  of  three  to  five  weeks.  Then  he  accidentally 
becomes  aware  that  there  is  a  single  pimple  upon  the  glans  penis  or  upon 
the  foreskin.  This  grows  and  becomes  quite  hard,  and  is  eroded  or 
ulcerated  upon  its  surface.  In  a  week  or  ten  days  the  glands  in  one 
or  both  groins  begin  to  swell,  yet  the  sore  itself  and  the  glands  are 
practically  painless,  and,  as  neither  of  them  attains  any  great  size,  the 
patient  may  neglect  to  consult  a  physician.  But,  though  relatively  in- 
sigTiificant,  the  sore  does  not  get  well ;  the  glands  do  not  disappear. 
Three  or  four  weeks  go  by  and  the  ulceration  upon  the  surface  of  the 
sore  gTadually  heals,  but  a  hard,  typical  lump  remains  under  the  epi- 
dermis. Then,  in  from  two  to  three  months  from  the  time  of  infection, 
the  first  general  symptoms  appear. 

At  or  before  the  onset  of  these  the  Wassermann  reaction  becomes 
positive. 

First,  he  begins  to  feel  a  little  miserable ;  his  bones  ache ;  he  feels 
perhaps  a  little  feverish,  but  probably  not  definitely  sick,  and  may  take 
no  very  gTeat  account  of  his  malady  until  he  notices  a  rash  upon  his 
body  or  some  sore  spots  in  the  mouth  or  pharynx.  These  are  pretty 
sure  to  bring  him  to  the  physician,  who  finds  him  with  a  characteristic 
macular,  papular,  or  polymorphous  eruption  (to  be  described  in  detail 
later),  with  little  sores  in  the  mouth  or  pharynx,  with  disseminated, 
minute,  scabbed  ulcerations  in  the  scalp,  perhaps  with  a  slight  evening 
rise  of  temperature,  and  tender  sternum  and  shins.  He  is  in  full  sec- 
ondary syphilis.     The  diagnosis  is  unmistakable. 

814 


DURATION  OF  PRIMARY  AND  SECONDARY  INCUBATION     815 

Onset  in  Woman — Such  is  the  course  followed  by  almost  all  men. 
In  women  the  onset  of  the  disease  is  by  no  means  so  characteristic.  The 
chancre  is  so  slight  a  lesion  that  it  is  usually  overlooked  by  the  patient, 
and  she  may  fancy  herself  entirely  well  until,  two  or  three  months  after 
infection,  she  begins  to  feel  run  down.  She  may  have  enough  fever  to 
fancy  she  has  malaria,  or  she  may  be  treated  for  an  imaginary  typhoid ; 
or  she  may  suffer  from  frightful  pains  in  her  bones,  in  her  head,  these 
pains  coming  on  in  the  evening  and  much  worse  at  night  than  during  the 
day.  A  short  while  after  the  beginning  of  this  outbreak  of  general 
toxemia  she  may  show  lesions  of  skin  and  mucous  membrane  quite  as 
characteristic  as  those  found  in  the  male.  But  in  a  certain  proportion  of 
cases  (9  per  cent)  these  objective  evidences  are  so  faint  as  to  be  over- 
looked and,  consequently,  she  does  not  present  a  typical  and  unmistak- 
able picture  of  the  disease.  In  such  cases  repeated  miscarriages,  or  the 
birth  of  children  that  promptly  die,  may  constitute  the  only  characteris- 
tic early  symptoms. 

If  the  diagnosis  is  not  made,  her  symptoms  may  gradually  abate, 
and  it  may  be  years  before  a  tertiary  outbreak  proves  that  she  has 
syphilis.  Or  she  may  go  on  to  have  some  characteristic  lesion  within  a 
few  weeks  or  months. 


DURATION  OF  PRIMARY  AND  SECONDARY  INCUBATION 

Such  is  the  beginning  of  syphilis  as  we  see  it  clinically. 

It  may  be  divided  into  two  periods :  the  primary  incubation,  ending 
with  the  appearance  of  the  primary  lesion — the  chancre — and  the  sec- 
ondary incubation,  ending  with  the  appearance  of  the  secondary 
lesions. 

The  extreme  limits  of  the  various  incubation  periods  are : 

First  incubation  (inoculation  to  chancre)  =  ten  days  to  six  weeks. 

Second  incubation  (appearance  of  chancre  to  secondaries)  =  within 
five  months. 

Total  incubation  (inoculation  to  secondaries)  ^  one  month  to  six 
months. 

But  if  the  patient  actually  has  syphilis,  it  is  rarely  necessary  to  wait 
so  long,  for  clinically  the  secondary  incubation  falls  within  three  months 
in  94  per  cent,  and  the  total  incubation  within  four  months  in  90  per 
cent  of  all  cases. 

The  Wassermann  reaction  always  becomee  positive  before  the  tenth 
week  after  the  appearance  of  chancre. 

What  might  be  termed  ''the  normal  case"  runs  a  primary  incuba- 
tion from  two  to  five  weeks,  a  secondary  incubation  from  one  to  three 
months,  a  total  incubation  from  six  weeks  to  four  months. 


816  THE  COUESE  OF  SYPHILIS 


THE  SECONDARY  LESIONS 


The  secondary  lesions,  if  anticipated  bv  treatment,  may  never  ap- 
pear. Indeed,  the  early  symptoms,  both  primary  and  secondary,  are 
entirely  overlooked  in  1  per  cent  of  men  (22  out  of  2,170  ^)  and  in  9 
per  cent  of  women  (18  out  of  207). 

Definition. — The  secondary  lesions  of  syphilis  are  twofold :  an  acute 
toxemia  and  certain  local  lesions  varying  in  character  from  simple  con- 
gestion to  exudation.  These  local  lesions  are  not  destructive  in  char- 
acter,  do  not  invade  the  adjoining  tissues,  do  not  undergo  caseation, 
and  on  healing  leave  little  or  no  scar.  They  have  usually  a  spontaneous 
tendency  to  heal. 

Secondary  Toxemia. — Examination  of  the  blood  during  the  first  few 
months  of  syphilis,  or  at  least  until  the  disease  is  controlled  by  treat- 
ment, reveals  a  chloro-anemia.  In  the  majority  of  cases  in  one's  private 
practice  this  condition  reveals  itself  but  by  one  symptom:  viz.,  loss  of 
weight.  One  very  frequently  finds  the  syphilitic  10,  20,  or  even  30 
pounds  lighter  at  the  end  of  six  months  than  he  was  the  day  of  his  in- 
fection.    This  loss  is  gradually  regained  under  treatment. 

On  the  other  hand,  typical,  severe,  syphilitic  toxemia  with  fever, 
prostration,  and  various  pains,  preceding  the  outbreak  of  the  localized 
secondary  symptoms,  is  so  rare  as  to  be  almost  always  mistaken  for 
malaria  or  typhoid  fever  until  the  eruptive  lesions  appear  and  establish 
the  diagnosis,  unless,  as  happened  to  a  youth  who  came  to  me  in  the  full 
glory  of  a  general  papular  syphilid,  it  suggests  measles. 

The  long-drawn-out  debility,  with  loss  of  weight  as  its  most  striking 
symptom,  is  much  more  severe  among  women. 

Local  Lesions. — The  first  local  secondary  lesion  appears  on  the  skin 
in  almost  every  case. 

This  first  eruption  is  macular  or  maculopapular,  and  generally  dis- 
tributed over  the  trunk,  less  marked  on  the  extremities.  Exceptionally, 
it  is  preceded  by  a  few  scattered  papules. 

The  Early  Secondary  Lesiois^s. — ^But  soon  a  whole  gTOup  of 
lesions  appears  to  form  a  characteristic  picture  of  early  syphilis.  The 
body  is  covered  with  macules  or  papules;  the  scalp  is  full  of  moist 
crustaceous  papules  ("scabs,"  the  patient  calls  them)  ;  there  are  pains  in 
the  joints,  the  bones,  the  muscles,  the  head;  the  mouth  and  throat  are 
filled  with  mucous  papules  and  erosions ;  the  hnnph  nodes,  especially 
the  epitrochlear  and  posterior  cervical,  become  enlarged,  while  the 
scar  of  the  chancre  with  its  satellite  adenitis  still  marks  the  port  of 
entry. 

Such  is  the  pathognomonic  picture  of  secondary  syphilis  at  its  out- 

^  Personal    statistics. 


"PARASYPHILIDS"  OR  QUATERNARY  LESIONS  817 

set.  The  picture  lasts,  in  any  or  all  of  its  constituents,  from  a  week  or 
two  to  a  month  or  two. 

The  Subsequent  Secondaky  Lesions. — After  the  subsidence  of 
this  first  outbreak  the  occurrence  of  secondary  symptoms  follows  no  rule. 
Lesions  of  the  skin  and  mucous  membranes  are  likely  to  relapse,  but  at 
what  intervals  one  cannot  prophesy.  A  surprisingly  large  proportion 
of  well-treated  cases — perhaps  three  in  five — have  no  further  secondary 
symptoms.    Relapses  are  most  frequent  in  the  first  year. 

Duration  of  Secondary  Lesions. — ^^Vhile  there  is  no  absolute 
term  to  relapses  of  secondary  lesions,  no  "secondary  period"  of  syphilis, 
yet  secondary  lesions  cease  within  the  first  four  years  in  about  90  per 
cent  of  cases,  within  six  or  seven  years  in  about  95  per  cent.  Secondary 
lesions  appearing  later  than  the  tenth  year  are  the  rarest  exceptions. 

THE  TERTIARY  LESIONS 

Definition. — Those  lesions  of  syphilis  which  are  localized  and  de- 
structive of  tissue  are  called  tertiary.  They  consist  of  relatively  diffuse 
infiltrations  terminating  in  the  production  of  masses  of  scar  tissue  or 
of  relatively  localized  masses  (gummata)  tending  to  central  caseation. 
The  tertiary  lesions  show  little  tendency  to  heal  spontaneously,  but 
spread  to  the  surrounding  tissue,  advancing  in  a  circular  or  circinate 
way  and  destroying  every  tissue  encountered  in  truly  malignant  fashion. 

Occurrence — The  majority  of  cases  of  syphilis  as  we  see  it  today 
do  not  have  any  tertiary  lesions. 

Tertiaries  make  their  appearance  more  often  in  the  second  and  third 
years  of  the  disease  than  in  any  other  two  years;  even  in  the  first 
year  they  are  by  no  means  uncommon  (6  per  cent,  Fournier;  13  per 
cent,  Keyes).  In  half  the  cases  they  appear  first  within  three  (Keyes) 
to  seven  (Fournier)  years  after  the  chancre.  The  beginning  may  be  de- 
ferred for  an  almost  indefinite  time.  Among  my  cases  the  four  longest 
deferred  began  at  thirty  (twice),  thirty-one,  and  forty  years. 

Relapses.- — The  intermittent  or  relapsing  character  of  syphilis  is 
most  evident  in  its  tertiary  lesions.  Relapses  of  secondary  lesions 
usually  occur  at  relatively  short  intervals  of  a  few  months;  tertiary 
relapses  at  longer  intervals. 

About  one-third  of  my  cases  of  tertiarism  relapsed,  and  about  half 
of  these  relapsing  cases  recurred  no  more  after  two  years. 

THE  "PARASYPHILIDS"  OR  QUATERNARY  LESIONS 

Definition. — The  parasyphilids  or  quaternary  lesions  arc  late  mani- 
festations of  the  disease  (such  as  tabes,  paresis,  and  aortic  aneurysm) 


818  THE  COURSE  OF  SYPHILIS 

the  actual  syphilitic  nature  of  which  has  only  been  proven  of  late 
years.  Clinically  they  are  sclerotic  and  destructive  in  type  and  hence 
rebellious  to  treatment. 

PROGNOSIS 

The  general  prognosis  of  syphilis  is  a  gloomy  prospect  compounded 
of  various  follies  amid  which  madness  for  drink  and  carelessness  in 
treatment  stand  pre-eminent.  Yet  intelligently  treated  syphilitics  re- 
main singTilarly  free  from  gTave  relapses,  a  freedom  which  I  believe 
they  owe  to  the  system  of  treatment  followed,  and  constant  insistence 
upon  the  fact  that  relapses  can  neither  be  foreseen  nor  absolutely  pre- 
vented by  any  system  of  treatment.  If  the  patient  is  made  to  recognize 
that  he  cannot  be  guaranteed  against  relapse  in  his  own  person  (however 
sure  he  may  be  that  he  is  no  longer  infectious)  he  is — sanely — on  his 
guard. 

In  short,  a  case  of  syphilis  intelligently  treated  and  properly  con- 
ducted usually  terminates  with  the  cessation  of  treatment  at  the  end  of 
three  years  in  all  things  except  the  matrimonial  guarantee,  which  is 
habitually  to  be  reserved  for  two  years  longer. 

What  proportion  of  such  cases  are  doomed  to  aortitis,  myocarditis 
or  syphilis  of  the  nervous  system  can  not  be  accurately  estimated.  My 
personal  impression  is  that  it  is  small.  The  present  outcry  ^  over  these 
conditions  is  largely  founded  upon  hospital  observation  of  a  class  of 
patients  who  certainly  are  not  likely  to  be  cured  in  any  sense. 

The  elements  of  the  prognosis  are: 

1.  The  patient's  constitution. 

2.  His  environment. 

3.  His  habits,  chiefly  as  regards  alcohol  and  tobacco. 

4.  His  treatment. 

5.  The  lapse  of  time. 

THE  PATIENT'S  CONSTITUTION 

In  syphilis,  as  in  any  other  disease,  the  most  important  element  of 
prognosis  is  the  way  the  patient  happens  to  react  to  the  infection. 

But  the  effect  of  the  constitution  of  the  patient  upon  the  course  of 
the  disease  is  by  no  means  limited  to  the  bald  moderation  or  intensifica- 
tion of  symptoms.  Syphilis  brings  out  every  latent  weakness.  It  en- 
courages the  development  of  tuberculosis.  It  plunges  the  hysterical  and 
the  neurasthene  into  new  depths  of  despair.  It  feeds  every  organic 
neuropathic  predisposition.  On  the  other  hand,  the  syphilis  itself  is 
colored  by  every  tinge  of  heredity — diathesis  and  temperament  alike. 

^Cf.  Warthin,  Am.  Jour.  Med.  Scl,  Oct.,  1916. 


PROGNOSIS  819 

The  anemic  or  "scrofulous"  victim  suffers  intensely  from  early  toxemia, 
florid,  general  early  skin  lesions,  and  mucous  membrane  lesions  of  a 
most  persistent  relapsing  character.  The  neuropath  is  stricken  in  his 
point  of  least  resistance.  Worst  of  all,  "syphilis  and  civilization"  are 
the  cause  of  paresis  and  tabes.  In  short,  syphilis  assumes  the  habit 
of  its  victim.     Its  course  depicts  his  weakness. 

The  recent  suggestion  that  certain  strains  of  spirochetes  may  have 
special  affinity  to  the  nervous  system  is  interesting,  but  awaits  final 
demonstration. 

THE  PATIENT'S  ENVIRONMENT 

Syphilis,  like  character,  is  founded  upon  heredity  modified  by  en- 
vironment. Every  influence  to  which  the  patient  is  subjected  may  react 
upon  his  disease. 

THE  PATIENT'S  HABITS 

Since  the  patient's  native  immunity  to  syphilis  is  his  most  impor- 
tant asset,  to  fortify  that  immunity  should  be  his  constant  effort.  Dur- 
ing the  first  years  of  the  disease  he  should  keep  "in  training."  Regular 
hours,  simple  food,  plenty  of  sleep,  fresh  air,  and  exercise  should  be  his 
rule  of  life  in  so  far  as  his  position  permits.  A  regard  for  the  ele- 
mentary rules  of  hygiene  is  always  helpful,  and  is  in  some  cases  of 
syphilis  as  important  as  in  tuberculosis.  Unfortunately,  many  syph- 
ilitics  grossly  neglect  the  rules  of  hygiene,  and  yet  come  to  no  immedi- 
ate, manifest  harm.  Consequently,  they  treat  lightly  the  warning  that 
bids  them  look  to  a  more  or  less  distant  and  problematical  future;  they 
neglect  to  make  every  effort  to  stamp  out  the  disease  while  it  is  yet 
young,  and  in  later  years  they  return  groaning  under  afflictions  that 
were  quite  p'reventable. 

Alcohol — The  reaction  of  alcohol  upon  syphilis  epitomizes  the  ef- 
fects of  bad  environment  and  evil  habits.  Alcohol  is  the  commonest  as 
well  as  the  most  active  enemy  of  the  syphilitic.  Malignant  early  syph- 
ilis is  most  frequent  among  those  who  have  been  alcoholic,  malignant 
late  syphilis  among  those  who  remain  alcoholic. 

In  debating  the  effect  of  alcoholism  in  syphilis  a  strict  definition  of 
the  term  is  essential.  By  alcoholism  is  meant  chronic  intoxication  by 
alcohol.  This  does  not  imply  drunkenness.  A  man  may  die  of  alco- 
holism without  ever  being  drunk.  Indeed,  the  man  who  boasts  that  he 
cannot  get  drunk  has  the  opportunity  of  becoming  far  more  alcoholic 
than  he  who  is  laid  low  by  a  stein  of  beer ;  and  it  is  precisely  among 
these  hardy  and  incessant  drinlcers  that  the  most  pronounced  evil  ef- 
fects may  be  looked  for.  Persistent  drinking  may  make  it  impossible 
to  prevent  or  to  cure  tertiary  relapses. 

But  the  essential  evil  of  alcoholism  is  not  that  it  so  often  makes  the 


820  THE  COURSE  OF  SYPHILIS 

lesions  of  syphilis  virulent  and  hard  to  cure,  but  that  it,  combined  with 
inefficient  treatment  (and  the  two  go  hand  in  hand ),  is  almost  the  whole 
cause  of  late  syphilis. 

Tobacco. — The  ill  effect  of  tobacco  is  immediate,  local,  and  obvious. 
If  it  excites  mouth  lesions  it  must  be  stopped,  but  otherwise  it  may  be 
used  in  moderation. 

TIME  AND  TREATMENT 

Time  and  treatment  are  the  enemies  of  syphilis.  Age  certainly  does 
wither  her  though  time  cannot  be  said  to  stale  her  infinite  variety.  If 
the  disease  relapses,  appropriate  treatment  diminishes  by  fully  80  per 
cent  the  prospect  of  further  relapse,  though  under  this,  as  under  any 
other  geometric  progTession,  an  infinite  number  of  relapses  is  possible. 

It  is  believed  that  salvarsan  administered  during  the  primary  stage 
cures  syphilis.  I  hope  that  this  is  true.-^  Yet  the  one  thing  we  really 
know  about  the  ultimate  results  of  salvarsan  is  that  they  are  not  all 
perfect. 

MORTALITY 

Life  insurance  statistics  are  the  best  foundation  we  have  for  esti- 
mating the  mortality  from  syphilis,  but  we  cannot  estimate  the  degTee 
of  inaccuracy  introduced  by  the  fact  that  the  least  scarred  patients  are 
the  most  likely  to  lie  about  their  previous  history  of  syphilis.  These 
statistics  seem  to  show  that  the  average  expectation  of  life  of  the 
syphilitic  insured  is  reduced  five  years,  and  that  at  least  15  per  cent  of 
syphilitics  die  as  a  result  of  their  disease.  Such  deaths  occur  from  20 
to  30  years  after  infection,  i.  e.,  between  the  fortieth  and  sixtieth  year 
of  life.^  Matauschek  and  Piltz  ^  analyzed  the  late  results  of  syphilis 
among  4,000  Austrian  army  officers  who  had  been  infected  from  12 
to  22  years:  546  were  dead  (83  by  suicide,  147  by  tuberculosis,  17  by 
aneurysm,  101  by  disease  of  the  circulatory  system,  71  of  renal  and  12 
of  hepatic  disease,  and  91  of  disease  of  the  nervous  system).  Of  those 
remaining  alive  198  had  paresis,  113  tabes,  and  132  cerebrospinal  syph- 
ilis, of  whom  80  were  insane.  They  estimate  that  14.64  per  cent  had 
died  of  the  disease,  or  were  chronic  invalids  as  a  result  of  it.  It  would 
be  interesting  in  this  connection  to  know  what  percentage  of  non-syph- 
ilitic Austrian  army  officers  dies  as  a  result  of  their  manner  of  life. 

^Boas  (Ugeskrift  f.  Laeger.,  Sept.  14,  1916)  reports  two  carefully  treated  and 
inspected  cases  whose  first  secondary  symptoms  occurred  in  the  second  and  third 
years  after  apparently   successful   abortive   treatment  with   salvarsan   and  mercury. 

^Berlin,  hlin.  Wochenschr.,  1915,  lii,  1057. 

'Med.  Klin.,  1913,  ix,  1544. 


CHAPTER    LXXXIV 

DIAGNOSIS  OF  SYPHILIS 

MEANS  OF  DIAGNOSIS 

The  means  of  diagnosing  syphilis  may  be  classified  as  follows : 

1.  Laboratory  Diagnosis. — Examination  for  spirochetes. 

Inoculation  of  monkeys. 
Specific  reaction. 
Examination  of  the  blood. 
Examination    of    syphilitic   tissue    (bi- 
opsy). 

2.  Clinical  Diagnosis. — History. 

Scars  of  previous  lesions. 
Appearance  of  the  present  lesion. 
Effect  of  treatment. 

Laboratory  Diagnosis. — Examixatio:s"  foe  Spirochetes. — The 
opinion  of  a  real  expert  is  valuable  confirmatory  testimony.  But  even 
the  most  expert  may  fail  to  find  the  spirochetes  when  present,  and  may 
think  he  sees  it  when  absent.  Hence  such  evidence  is  only  confirmatory. 
I  find  it  most  useful  in  the  differential  diagnosis  of  chancre  and  of 
buccal  sores. 

IjfocuLATiox  OF  MoxKEYS. — This  cau  never  be  generally  employed 
for  lack  of  subjects.    It  appears  to  be  a  reliable  test. 

Specific  Reaction's. — Cf.  p.  806. 

Examination  of  Syphilitic  Tissue. — A  snipping  from  the  lesion 
may  differentiate  giimma  from  neoplasm  or  tuberculosis. 

Clinical  Diagnosis. — Whereas  the  application  of  the  laboratory  tests 
is  limited  and  bound  to  conform  with  the  clinical  findings,  these 
latter  are  almost  universally  applicable.  We  are  therefore  much  better 
acquainted  with  the  limitations  of  our  clinical  tests^  and  in  the  present 
state  of  our  art  they  are  the  more  reliable. 

Yet  there  is  a  sharp  distinction  between  the  method  of  applying 
these  two  classes  of  tests.  The  laboratory  tests  are  applied  singly ;  the 
success  of  one  of  them  is  almost  as  convincing  as  though  they  all  coin- 
cided. But  the  clinical  tests  must  be  applied  all  together.  History  and 
scars  give  us  a  hint  of  what  may  he  the  trouble;  this  impression  is 

821 


822  DIAGNOSIS  OF  SYPHILIS 

strengthened  or  weakened  hj  the  appearance  of  the  lesion,  and  the 
laboratory  tests,  and  confirmed  or  refuted  by  the  effect  of  treatment. 
But  if  they  fail  to  agree  we  may  remain  in  doubt,  and  the  lesion  may 
heal  and  leave  us  there.  For  recovery  under  antisyphilitic  treatment 
is  no  proof  that  the  lesion  wsls  syphilitic. 

Enlarged  lymph  glands  are  the  exception  rather  than  the  rule  in 
syphilis.  Within  two  weeks  after  the  appearance  of  chancre  the  typical 
inguinal  adenitis  appears,  and  lasts  some  three  to  six  months.  General 
syphilitic  adenitis  usually  follows  close  upon  the  first  general  eruption, 
and  disappears  well  within  the  year.  Hence  syphilitic  adenitis  is  ex- 
tremely rare  after  the  first  year. 


DIAGNOSIS  AT  DIFFEEENT  PERIODS  OF  THE  DISEASE 

We  may  summarize  here  certain  diagnostic  situations  that  con- 
stantly come  up. 

The  Initial  Stage. — To  diagnose  syphilis  by  the  appearance  of  a 
chancre  one  must  find,  not  only  the  sore  and  the  regional  adenitis,  but 
also  spirochetes  or  a  positive  Wassermann  reaction. 

Unless  the  diagnosis  is  absolutely  fortified  by  these  precautions,  one 
is  not  licensed  to  begin  treatment  until  the  Wassermann  reaction  be- 
comes positive. 

The  Secondary  Outbreak. — Various  combinations  of  circumstances 
lead  to  a  diagnosis  at  the  time  of  the  secondary  outbreak.  The  positive 
Wassermann  reaction,  however,  dominates  the  clinical  scene. 

In  a  Period  of  Calm. — Within  the  first  six  months  typical  posterior 
cervical  and  epitrochlear  adenopathy  are  usually  found.  If  both  sets 
are  enlarged  and  the  patient's  history  is  suggestive  of  syphilis,  the 
chances  are  that  the  patient  has  the  disease,  and  it  is,  therefore,  safer  for 
him  to  continue  treatment  than  to  stop  it. 

After  the  first  six  months  there  is  often  no  trace  whatever  of  the 
disease.  In  this  event  we  must  depend  entirely  upon  the  history,  and, 
even  though  it  be  not  very  impressive,  it  is  usually  wiser  to  continue 
the  treatment  on  the  diagnosis  previously  given ;  for  there  are  no  means 
of  proving  that  the  patient  has  not  syphilis,  and  the  omission  of  treat- 
ment may  bring  him  grave  relapses  in  the  future. 

Later  Relapses. — The  diagnosis  rests  upon  the  Wassermann  and 
spinal  fluid  tests  and  the  characteristics  of  the  lesion  and  its  reaction 
to  appropriate  treatment.  Negative  laboratory  findings  should  not 
weigh  too  heavily  against  positive  clinical  evidence. 

Wassermann  Test — This  is  a  great  help  as  an  adjunct  in  diagnosis 
at  all  stages  of  the  disease.  The  provoked  Wassermann  should  be  freely 
employed. 


CHAPTER    LXXXY 
TREATMENT  OF  SYPHILIS 

PREVENTION 

The  prevention  of  syphilis  is  a  moral  as  well  as  a  hygienic  problem. 
To  the  moralist  it  presents  the  problem  of  elevating,  the  morals  of  the 
race  so  as  to  minimize  the  illicit  sexual  intercourse  from  which  most 
venereal  disease  takes  its  rise.  The  hygienic  problem  includes  the 
police  problem  of  the  suppression  of  prostitution,  and  the  incarceration 
of  infectious  prostitutes  and  criminals  until  they  are  cured,  the  Health 
Board  problem  of  abolishing  the  advertising  quacks,  providing  free 
Wassermann  diagnosis,  and  encouraging  early  and  efficient  treatment, 
and  individual  prophylaxis  (which  includes  inunction  of  the  penis  im- 
mediately after  sexual  intercourse  with  calomel  ointment  and  the 
diagnosis  of  all  chancres  by  means  of  spirochete  smears,  and  their 
prompt  treatment  by  salvarsan). 

Excision  of  the  chancre  does  not  abort  syphilis,  clinically  or  ex- 
perimentally, in  man  or  in  monkey. 


GENERAL  PRINCIPLES  OF  TREATMENT 

The  old-fashioned  treatment  of  syphilis  has  been  completely  swept 
to  one  side  by  the  success  of  our  newer  methods  of  diagnosis  and  thera- 
peutics. But  we  have  exchanged  for  the  danger  of  the  disease  itself 
dangers  inherent  in  the  remedies  which  we  employ.  The  old-fashioned 
mercurial  pill,  if  it  controlled  the  disease  little,  retarded  the  reaction 
of  the  sufferer  still  less.  But  unintelligent  employment  of  salvarsan 
may  bring  untold  suffering  to  the  patient  by  inducing  the  so-called 
neurorecidiv.  In  the  modern  treatment  of  syphilis  the  following  three 
rules  are  fundamental : 

Salvarsan  is  the  most  efficient  specific  for  active  lesions  of  syphilis, 
including  the  Wassermann  reaction. 

Mercury  must  he  employed  between  courses  of  salvarsan  for  the 
purpose  of  preventing  relapse  of  symptoms. 

Hygiene  is  quite  as  indispensable  under  the  new  as  under  the  old 
dispensation. 

823 


824  TREATMENT  OF  SYPHILIS 

Salvarsan  is  infinitely  more  efiicient  than  mercury  in  the  control 
of  active  lesions  of  the  disease,  but  salvarsan  may  perversely  reduce  the 
patient's  resistance  to  the  disease  even  more  than  it  does  the  disease 
itself.  While  killing  off  what  we  may  roughly  term  the  great  majority 
of  spirochetes,  it  reduces  the  patient's  resistance  below  what  might  be 
termed  a  normal  par.  Thus  the  patient  is  left  with  insufficient  re- 
sistance to  combat  the  spirochetes  remaining  in  his  body.  The  spiro- 
chetes in  the  nervous  system  are  usually  the  ones  to  escape  destruction, 
perhaps  owing  to  their  situation  within  the  meninges.  Hence  a  few 
months  after  the  administration  of  salvarsan  the  patient  is  likely  to 
suffer  a  neurorecidiv,  i.  e.,  a  relapse  of  syphilis  in  the  nervous  system. 
This  relapse  is  most  likely  to  occur  after  the  administration  of  salvarsan 
during  the  first  year  of  the  disease ;  but  it  is  occasionally  seen  later  on, 
and  there  is  good  reason  to  believe  that  some  cases  of  syphilis  moderately 
well  controlled  by  mercury,  although  they  may  be  brilliantly  cured  by 
salvarsan,  relapse  rather  more  viciously  after  this  than  they  did  before 
its  use.  Let  us  hasten  to  add,  however,  that  salvarsan  will  even  cure 
the  relapse  excited  by  the  salvarsan. 

On  the  other  hand,  mercury  can  claim  no  such  parasiticidal  quali- 
ties. It  destroys  the  spirochetes  little  by  little  or,  if  they  have  already 
been  destroyed  by  salvarsan,  it  continues  the  action  of  that  drug  and 
fortifies  the  sufferer  against  the  relapse  that  would  otherwise  ensue.  For 
this  purpose  it  is  not  sufficient  to  give  pills.  A  stronger  remedy  is  re- 
quired, and  this  is  provided  either  by  inunctions  or  injections  of  mer- 
cury.   These  should  be  given  before  as  well  as  after  the  salvarsan. 


TEEATMENT  OF  SYPHILIS  IN  THE  PRIMARY  STAGE  i 

If  the  chancre  is  diagnosed  before  the  Wassermann  reaction  becomes 
positive,  six  injections  of  salvarsan  should  be  given  at  intervals  of  from 
five  to  seven  days.  Gennerich  considers  this  sufficient  to  sterilize  the 
patient ;  I  prefer  to  continue  the  treatment  as  though  the  reaction  had 
been  positive.     (See  footnote  on  p.  820.) 

If  the  Wassermann  is  positive  before  treatment  is  begun  or  becomes 
positive  after  the  first  or  second  injection  the  six  salvarsan  injections 
are  usually  enough  to  render  it  negative.  Treatment  is  then  continued 
by  injections  or  inunctions  of  mercury  for  at  least  one  year  (as  in  the 
treatment  of  secondary  syphilis),  and  the  cure  confirmed  by  negative 
Wassermann  reactions  every  six  months  for  at  least  two  years  thereafter. 

^N.  Y.  State  Med.  Jour.,  1915,  xv,  425. 


TREATMENT  OF  THE  LATER  LESIONS  825 


TREATMENT  OF  SECONDARY  SYPHILIS 

All  authorities  are  agreed  that  a  prompt  cure  may  not  be  expected. 
The  six  injections  of  salvarsan  are  preceded  as  well  as  followed  by  the 
usual  intensive  mercurial  course  of  four  or  five  injections.  The  Was- 
sermann  reaction  is  taken  irrespective  of  treatment  every  six  months, 
and  the  courses  of  mercurial  injections  are  kept  up  as  follows: 

If  insoluble  mercury  is  used  a  course  consists  of  an  injection  every 
fifth  to  seventh  day  until  six  or  eight  injections  have  been  given.  The 
courses  are  repeated  in  this  way  with  an  intermission  of  a  month  be- 
tween each  throughout  the  first  year.  Four  courses  of  injections  are 
given  in  the  second  year,  two  in  the  third  year.  At  the  end  of  that 
time  it  is  wise  to  give  two  salvarsan  injections  as  a  provocative  in  order 
to  search  the  cure  and  to  examine  the  spinal  fluid,,  for  if  it  is  then  nega- 
tive the  central  nervous  system  may  probably  be  guaranteed  free  from 
danger.  For  two  years  longer  the  Wassermann  reaction  is  taken  every 
six  months.  If  it  has  remained  negative  throughout  this  time,  the 
patient  may  be  dismissed  as  cured — with  the  usual  reservation  that  an 
absolute  guarantee  is  impossible. 

Soluble  mercurial  injections  and  inunctions  are  given  in  similar 
courses,  each  course  of  twenty  to  thirty  daily  treatments. 


TREATMENT  OF  THE  LATER  LESIONS 

Later  lesions  are  treated  in  a  similar  manner.  Courses  of  from  four 
to  six  injections  of  salvarsan  being  employed  for  the  purpose  of  relieving 
symptoms  or  of  making  the  Wassermann  reaction  negative,  and  the 
patient  is  thereafter  fortified  by  a  treatment  with  mercurial  injection 
for  at  least  two  years,  though  it  is  customary  to  give  only  four  courses  of 
injections  in  each  year  instead  of  six  courses  in  the  first  year  as  in  the 
treatment  of  secondary  syphilis. 

If  the  Wassermann  reaction  does  not  become  negative,  or  the  lesions 
do  not  yield,  special  stress  must  be  laid  upon  hygiene  and  the  courses 
of  salvarsan  repeated  not  more  than  twice  a  year.  If  the  blood  Wasser- 
mann reaction  is  rebellious  to  four  such  courses,  and  the  spinal  fluid 
shows  no  disease  in  the  nervous  system,  even  Ehrlich  himself  has  ad- 
vised that  one  desist  from  further  treatment.  I  have  followed  one  case 
with  a  fixed  positive  Wassermann  for  seven  years,  yet  his  Wassermann 
remains  positive  and  he  remains  perfectly  well. 


826  TREATMENT  OF  SYPHILIS 

TREATMENT  OF  SYPHILIS  IN  THE  NERVOUS  SYSTEM 

Many  lesions  of  the  nervons  system  yield  to  tlie  routine  treatment 
described  above.  We  are  just  now  in  the  midst  of  a  crusade  which  has 
for  its  object  the  elimination,  not  only  of  symptoms  of  nervous  disease, 
but  also  of  the  pathologic  changes  in  the  cerebrospinal  fluid  by  the  ad- 
ministration of  drugs  directly  into  the  cerebrospinal  space.  Sufficient 
time  has  not  elapsed  for  judgment  to  be  passed  upon  this  treatment, 
but  the  following  rules  may  be  laid  doT\Ti: 

1.  The  Swift-Ellis  salvarsanized  serum  treatment  is  probably  much 
the  safest  of  the  various  methods  employed. 

2.  Even  this  treatment  is  uncomfortable,  requires  hospital  confine- 
ment, sometimes  results  in  paralysis  of  the  bladder  and  bowel  and  of 
the  lower  extremities,  and  even  in  death:  hence  it  should  only  be  em- 
ployed by  an  expert  neurologist  or  serologist. 

3.  The  treatment  has  proven  quite  efficacious  in  rebellious  cases  of 
tabes,  but  its  efficacy  in  developed  paresis  is  still  doubtful. 

SALVARSAN 

Salvarsan  or  "606"  is  to  be  preferred  to  neosalvarsan.  The  latter 
is  estimated  to  be  one-quarter  as  efficient  as  the  former.  But  it  is  safer 
for  administration  by  the  house  staff,  since  infiltration  of  the  tissues 
with  neosalvarsan  does  not  produce  the  sloughing  which  infiltration 
with  old  salvarsan  most  emphatically  does. 

Intramuscular  Injections. — The  original  methods  of  intramuscular 
injection  of  salvarsan  were  fantastically  cruel.  They  left  the  patient 
writhing  in  pain  for  a  week  or  two  after  the  injection.  American  drug 
houses  are  putting  out  suspensions  of  salvarsan  in  various  oily  media 
for  intramuscular  injection  in  doses  of  about  1  dscigTam  each.  I  have 
never  employed  the  drug  in  this  manner,  and  should  judge  from  the 
experience  of  the  army  ^  that  repeated  intravenous  injections  are  likely 
to  prove  much  more  efficient  than  repeated  intramuscular  injections. 
The  intramuscular  injections,  as  at  present  employed,  are  given  in 
much  the  same  manner  as  injections  of  mercury,  in  interrupted  courses. 

Intravenous  Injections. — ()u  account  of  the  deaths  resulting  from 
the  intravenous  a<lministration  of  salvarsan  this  has  been  surrounded 
by  a  number  of  rather  fantastic  requirements.  Thus  it  is  insisted 
that  the  glass  in  which  the  solution  is  mixed  shall  be  alkali-free,  and 
that  the  water  shall  be  both  distilled  and  boiled ;  and  it  is  promised  that 
as  the  result  of  such  precautions  no  mishaps  will  occur.     I  always  em- 

^ Surgeon-General's  Bid.,   No.   3,   .June,    1913. 


SALVARSAN  827 

ploy  distilled  aud  boiled  water ;  I  have  never  used  an  alkali-free  glass 
bottle.  I  cannot  say  that  my  mishaps  are  any  fewer  since  I  used  dis- 
tilled water  than  they  were  when  the  water  was  simply  boiled.  The 
original  technic  calls  for  the  administration  of  300  c.c.  of  fluid.  At 
present  the  usual  allowance  is  10  c.c.  of  distilled  water  for  every  deci- 
gram of  the  drug  to  be  injected. 

The  dose  for  an  adult  male  is  3  to  4  decigrams ;  for  an  adult  woman, 
3  decigrams ;  for  an  infant,  1  centigram. 

The  bend  of  the  elbow  is  sterilized,  and  a  tourniquet  applied  above 
it  so  as  to  distend  the  veins  while  the  patient  holds  his  elbow  stiff  and 
his  hand  tightly  clenched.  Meanwhile  the  distilled  water  is  warmed 
to  about  blooi  heat  and  a  tube  of  salvarsan  emptied  into  a  glass-stop- 
pered bottle  containing  30  c.c.  of  this  warm  water.  This  is  violently 
agitated  for  some  minutes  until  the  salvarsan  is  thoroughly  dissolved, 
even  the  glass-like  sticky  particles  having  disappeared.  To  this  is 
added,  drop  by  drop,  a  15  per  cent  solution  of  chemically  pure  sodium 
hydrate.  AVith  the  second  or  third  drop  the  solution  becomes  cloudy, 
with  the  fifth  or  sixth  it  becomes  clear.  Only  enough  sodium  hydrate 
should  be  added  to  absolutely  clarify  the  solution.  If  some  particles 
remain  in  suspension  they  may  be  cleared  by  filtration  through  a  sterile 
cotton  filter. 

The  injection  is  made  either  by  gTavity  or  with  a  30  c.c.  piston 
syring^e,  or  by  a  syringe  to  which  is  attached  a  three-way  stop-cock,  and 
one  rubber  tube  leadinsr  into  the  bottle  containing'  the  salvarsan  while 
another  leads  to  the  needle  in  the  patient's  arm.  Whatever  the  method 
employed  it  is  essential  that  the  salvarsan  be  given  slowly  and  that  at 
least  five  and  preferably  ten  minutes  be  taken  for  the  injection  of  the 
30  c.c.     Therefore  the  gravity  method  is  the  safest. 

It  is  further  absolutely  essential  that  the  needle  be  actually  in  the 
lumen  of  the  vein  when  the  injection  is  given.  If  the  solution  is  in- 
jected into  the  cellular  tissue  about  the  vein  a  frightful  slough  will 
result,  the  patient  will  have  an  incapacitated  arm  for  from  three  to 
six  months,  and  a  permanently  disfiguring  scar  thereafter. 

Immediate  Accidents — The  patient  should  always  be  lying  down 
when  the  injection  is  given,  but  even  so  he  may  get  quite  a  sharp  im- 
mediate reaction,  shown  first  by  a  reddening  of  the  skin,  a  sense  of 
fullness  in  the  head,  and  of  rapid  heart-beat  followed  by  a  faintness 
with  great  pain  in  the  epigastrium  and  loin.  During  this  period  the 
pulse  becomes  almost  imperceptible  and  the  patient  is  in  a  condition 
of  severe  shock.  This  anaphylactic  reaction  is  said  to  be  most  common 
after  the  second  injection.  It  may,  however,  be  averted  by  injection 
under  the  skin  at  the  first  sign  of  fliisliing  of  tlio  patient's  face  of  10 
minims  of  1 :  1,000  solution  of  adrenalin.  This  injection  should  not 
be  made  intravenously. 


828  TREATMENT  OF  SYPHILIS 

Toxic  Results. — ^Patients  have  died  following  tlie  injection  of  sal- 
varsan  of  acnte  encephalitis  and  of  acute  congestion  of  the  kidney. 
The  latter  is  by  far  the  most  common  cause  of  death,  and  is  an  accident 
that  cannot  perhaps  be  wholly  avoided,  though  the  injection  of  salvarsan 
should  always  be  preceded  by  a  careful  examination  of  the  kidney  and 
urine.  If  this  is  abnormal  and  contains  albumin  and  casts  and  shows  a 
deficient  excretion  of  urea,  the  salvarsan  should  only  be  given  in  -J  or 
^  of  the  usual  dose.  I  have  lost  one  patient  by  acute  nephritis ;  he  died 
anuric  and  jaundiced  on  the  fourteenth  day  after  his  second  injection 
of  3  decigrams.  I  have  lost  but  one  other  case,  who  died  apparently  of 
pulmonary  embolism  just  after  I  had  given  him  his  sixth  injection. 
(His  syphilitic  lesion  was  a  hemiplegia  due  to  rupture  of  a  blood  vessel 
at  the  base  of  his  brain.)  As  compared  with  these  extremely  rare 
fatalities  (which  are  said  to  occur  once  in  five  thousand  cases)  one 
not  uncommonly  sees  evidences  of  mild  intoxication  following  the  injec- 
tion of  even  small  doses  of  salvarsan.  About  half  the  cases  have  a 
slight  rise  of  temperature  from  one  to  four  hours  after  the  injection. 
This  rise  is  occasionally  sharp  enough  to  be  accompanied  by  a  violent 
chill  and  fever.  By  the  end  of  an  hour  all  is  approximately  normal 
again.  At  about  this  same  period  the  patient  may  be  seized  with  violent 
projectile  vomiting  and  diarrhea  or  this  may  come  on  the  following 
day.  It  usually  lasts  for  an  hour  or  so  but  may  last  for  several  days; 
A  few  days  after  the  injection  of  salvarsan  it  is  not  uncommon  for  the 
patient  to  show  erythema,  urticaria,  coryza,  sore  throat,  indigestion,  or 
diarrhea ;  evidences  grouped  as  anaphylactic. 

In  the  early  days  of  salvarsan  administration  optic  neuritis  fre- 
quently resulted  from  the  use  of  wood  alcohol  as  a  solvent  for  the  drug. 
Since  optic  neuritis  was  known  to  result  from  the  administration  of 
Fowler's  solution  and  atoxyl  the  lesion  was  erroneously  attributed  to 
the  arsenic.  Eut  with  the  elimination  of  wood  alcohol  from  the  solu- 
tion optic  neuritis  is  scarcely  mentioned,  except  as  a  neurorecidiv.  I 
have  seen  the  complication  but  once  (a  week  after  the  third  injection  of 
3  decigrams  to  a  patient  with  chancre.     It  disappeared  within  a  month.) 

Neurorecidiv  and  Other  Relapses — The  chancre  redux  (falsely  in- 
terpreted as  a  second  attack  of  syphilis),  relapse  of  syphilis  in  the 
nervous  system  (usually  in  the  form  of  deafness  or  facial  paralysis), 
and  other  relapses  of  the  disease,  occurring  usually  from  three  to  six 
months  after  the  administration  of  salvarsan,  are  perhaps  the  most 
discouraging  of  the  many  complications  of  salvarsan  therapy.  Such 
relapses  are  most  frequent  when  the  drug  is  administered  in  the  first  six 
months  of  the  disease  (the  Wassermann  reaction  usually  remaining 
negative).  They  can  apparently  be  prevented  by  the  preliminary  and 
subsequent  "guardian"  mercurial  injections. 

Later  in  the  disease  it  will  be  noted  that  symptoms  of  cerebrospinal 


MERCUHY  829 

lesions,  especially  the  mental  sjTnptoms  of  paresis,  may  be  aggravated 
by  salvarsan,  especially  if  ungiiarded  by  mercury. 

It  must  be  further  confessed  that  salvarsan  sometimes  exhibits 
this  curious  stimulating  effect  upon  syphilitic  relapses  even  more  re- 
motely and  obscurely.  "While  the  majority  of  cases  derive  nothing  but 
benefit  from  the  drug  a  certain  few  seem  to  show  a  vicious  tendency  to 
relapse  after  salvarsan.  The  vigor  of  salvarsan  therapy  at  the  present 
day  will  soon  determine  the  clinical  significance  of  such  cases. 

Centra-indications — There  are  no  absolute  contra-indications  to  the 
use  of  salvarsan.  Grave  visceral  disease  contra-indicates  large  doses 
of  this,  as  of  any  other  drug.  Renal  complications  are  of  the  most 
importance,  for  Wechselman  ^  maintains  that  hemorrhagic  encephalitis 
is  due  to  nephritis.  He  believes,  however,  that  this  nephritis  is  mercu- 
rial in  origin  and  argues  that  mercury  should  be  abandoned  and  syphilis 
be  treated  exclusively  by  salvarsan.  At  the  present  writing,  however, 
the  opposite  theory  prevails,  the  many  complications  of  salvarsan 
therapy  having  produced  a  revulsion  in  favor  of  mercury.  Indeed,  it 
will  doubtless  require  many  years  of  clinical  experience  thoroughly 
to  thrash  out  the  question  of  the  relative  contra-indications  to  salvarsan. 
It  has  quite  fallen  from  its  high  estate  as  sovereig-n  remedy.  ]\rany 
lesions  can  unquestionably  be  controlled  without  it.  Only  the  ultimate 
outcome  of  the  cases  now  being  treated  by  salvarsan  can  decide  its  true 
value. 

At  present  it  must  be  employed  always  in  the  primary  period  and 
for  the  cure  of  lesions  that  mercury  fails  to  control,  especially  the  per- 
sistently positive  Wassermann  reaction.  It  may  be  used  in  all  cases, 
if  guarded  by  mercury ;  but  with  what  ultimate  effect  we  do  not  know. 

It  is  especially  questionable  whether  provocative  salvarsan  injec- 
tion does  not  sometimes  provoke  real  activity  in  a  dormant  syphilis. 


MERCURY 

.  The  great  disagreement  that  exists  in  the  profession  today  con- 
cerning the  mercurial  treatment  of  syphilis  is  founded  essentially 
upon  the  great  variation  in  the  virulence  of  syphilis,  especially  its  early 
virulence.  Some  cases  of  the  disease  do  perfectly  well  for  the  first 
few  years  without  any  treatment  at  all,  so  well,  indeed,  that  their 
condition  may  pass  unrecognized.  Others  do  equally  well  on  treatment 
that  consists  solely  of  the  administration  of  mercurial  pills  and  solu- 
tions of  potassium  iodid.  But  many  cases  are  not  controlled  by  these 
drugs  even  during  the  first  years  of  the  disease.  Such  cases  demonstrate 
the  efficiency  of  salvarsan  and  of  mercury  administered  intramuscularly 
*"Ueber  der  Pathogenese  d.  Salvarsans-todes-faelle,"  Berlin,   1914. 


830  TREATMENT  OF  SYPHILIS 

or  by  inunction.  These  methods  of  treatment  promptly  control  lesions 
that  had  long  been  rebellious  to  internal  treatment. 

On  the  other  hand,  the  contemplation  of  the  late  lesions  of  syphilis 
shows  that  the  mild  internal  treatment  leaves  much  to  be  desired. 
Tabes  and  paresis  occur  almost  exclusively  in  patients  whose  treatment 
would  seem  totally  inefficient  according  to  our  modern  standard.  Vis- 
ceral syphilis,  notably  syphilis  of  the  liver,  the  heart,  and  the  aorta, 
is  the  heritage  of  the  present  generation  from  the  "pill  and  potash" 
of  the  preceding  one. 

It  is  not  yet  proven  that  the  most  intensive  treatment  will,  in  the 
long  run,  cure  or  even  control  syphilis.  But  this  intensive  treatment, 
as  far  as  mercury  is  concerned,  has  been  employed  for  at  least  a  decade 
in  this  country  and  for  a  generation  in  Europe.  Controlled  by  the 
blood  Wassermann  reaction  and  the  spinal  fluid  reactions  and  aided  by 
the  brilliant  immediate  efficiency  of  salvarsan,  there  is  every  reason 
to  predict  that  the  next  generation  will  inherit  from  us  a  far  smaller 
toll  of  syphilitic  cripples. 

But  even  were  this  not  the  case  it  is  imperative,  as  already  stated, 
that  the  violence  of  salvarsan  be  matched  with  the  violence  of  mercury 
by  injection  or  inunction.  If  this  is  not  done  the  patient  may,  within 
a  year  or  so  be  in  a  worse  state  than  if  salvarsan  had  not  been  employed. 

For  these  reasons  we  deplore  treatment  by  pills  and  prefer  to  ignore 
this  method  of  administering  mercury. 


TOXICOLOGY  OF  MERCURY 

Salivation — Salivation  is  the  commonest  form  of  mercurial  poi- 
soning.    It  may  occur  from  the  use  of  mercury  under  any  form. 

Symptoms  of  Mild  Salivation. — The  first  symptom  noted  by  the 
patient  is  a  coppery  taste  in  the  mouth.  This  is  accompanied  by  a  very 
heavy  disagreeable  odor  to  the  breath ;  the  tongue  and  cheeJcs  become 
edematous  and  show  the  marks  of  the  teeth;  the  gums  bleed j  the  teeth 
feel  sore  and  elongated. 

Examination  of  the  gums  reveals  localized  areas  of  congestion,  espe- 
cially about  the  lower  incisors  or  about  any  decayed  tooth.  When  the 
lesions  are  more  pronounced  the  giims  actually  ulcerate.  The  pathog- 
nomonic mercurial  ulceration  appears  behind  the  lower  incisors  and 
back  of  the  lower  wisdom  teeth.  Ulcerations  may  occur  elsewhere  in  the 
mouth,  and  it  may  be  almost  impossible  to  distinguish  the  lesions  due 
to  the  medicine  from  those  caused  by  the  disease. 

Actual  salivation  is  usually  slight  at  first,  though  in  some  cases  the 
excessive  flow  of  saliva  is  the  earliest  symptom. 

Symptoms  of  Severe  Salivation. — Nowadays  one  does  not  see 


TOXICOLOGY  831 

"good,  old-fashioned"  salivation,  the  patient  depressed,  feverish,  stu- 
pid, his  tongue  swollen  beyond  recognition  and  gangrenous  in  spots,  a 
constant  stream  of  ropy  saliva  drooling  from  his  swollen  lips,  his  teeth 
loosened  and  falling,  even  his  jaws  becoming  necrotic,  and  his  breath 
permeating  the  atmosphere  with  an  intensely  disgusting  fetid  odor. 

Treatment  of  Salivation. — So  important  is  the  care  of  the  mouth 
in  the  prophylaxis  of  salivation  that  the  patient  about  to  take  a  course  of 
mercury  should  be  carefully  instructed  how  to  keep  his  mouth  in  good 
condition. 

He  must  first  have  his  teeth  filled  and  thoroughly  cleaned  by  a 
dentist. 

He  must  brush  his  teeth  morning  and  night. 

He  must  smoke  little.^ 

He  must  report  the  instant  his  gums  become  swollen  or  sore — at 
which  time  mercury  must  be  suspended. 

The  treatment  of  mild  salivation  consists  in  painting  the  gums  with 
one  of  the  following  solutions : 

T^   Tr.  myrrh.,      1  ' 

Tr.  iodi  comp.,  I aa  3j  (4  gm.). 

Aquae,  J 

S. — Apply  to  gums  once  or  twice  a  day. 
Or 

I^   Acid  lactic 5j  (4  gm.). 

Aquae 3ij  (8  gm.). 

S. — Apply  to  gTims  once  a  day  (Tennesson). 

Almkvist  ^  states  that  salivation  is  due  to  sulphid  of  hydrogen  about 
the  teeth  roots,  resulting  from  bacterial  action  upon  the  mercury.  He 
praises  the  injection  of  strong  (20  per  cent)  peroxid  of  hydrogen  be- 
tween tooth  and  gum. 

]\:!^eanwhile,  let  the  patient  suck  during  the  day  two  or  three  tablets 
(aa  gr.  v)  of  chlorate  of  potash. 

The  bowels  must  be  kept  open  (they  are  usually  loose,  anyway)  and 
the  mercury  stopped. 

For  severe  cases,  free  purging  and  diuresis,  hot  baths,  a  milk  diet, 
and  suspension  of  the  mercury  constitute  the  most  important  treatment. 
The  local  applications  may  be  used  as  in  mild  cases.  Ulceration  of 
the  cheeks  may  be  lessened  by  separating  them  from  the  teeth  with 
pledgets  of  cotton  dipped  in  boric  acid  solution  or  with  a  piece  of  raw 
turnip. 

^I  am  riot  sure  that  the  irritation  of  tobacco  is  an  important  contributory- 
cause  of  salivation,  but  I  know  it  predisposes  the  patient  to  syphilitic  mouth 
lesions. 

'Hygiea,  Aug.  15,  1915. 


832  TREATMENT  OF  SYPHILIS 

Enterocolitis. — A  sharp  diarrhea  with  colic  usually  accompanies 
severe  salivation. 

To  prevent  this  is  the  art  of  managing  mercury. 

To  cure  it  stop  the  mercury,  put  the  patient  on  a  fluid  diet  without 
milk,  and,  after  giving  a  sharp  purge,  administer  bismuth  (gr.  x),  beta- 
naphthol  bismuth  (gr.  x),  or  opium. 

Mild  cases  are  promptly  relieved  by  stopping  the  mercury. 

Nephritis. — The  normal  kidney  secretes  mercury  in  small  doses 
perfectly  kindl}' .  But  mercury  may  produce  congestion  of  the  kidney 
or  nephritis  either : 

1.  When  the  kidneys  are  diseased,  or 

2.  When  mercury  is  given  in  poisonous  dose. 

Any  form  of  acute  or  chronic  nephritis  makes  the  kidneys  a  poor 
filter  for  mercury,  and  since  mercurial  nephritis  is  the  rarest  form  of 
mercurial  poisoning,  there  is  always  room  for  suspicion  that  the  kidney 
is  chiefly  at  fault.  This  is  further  emphasized  by  the  fact  that  there 
occurs  an  acute  secondary  syphilitic  nephritis  which  may  be  mistaken 
for  mercurial  nephritis. 

The  chief  practical  point  in  regard  to  nephritis  is  that  the  urine 
should  l>e  examined  tvhen  mercurial  treatment  is  instituted,  and  should 
he  repeatedly  examined  during  any  severe  course  of  mercury. 

Albuminuria  or  nephritis  does  not  contra-indicate  the  adminis- 
tration of  mercury,  but  does  give'  warning  that  it  must  be  given  in 
small  doses  and  with  constant  attention  to  the  condition  of  the  renal 
function. 

Dermatitis — Some  skins  are  very  sensitive  to  inunction,  and  in 
general  the  hairy  portions  of  the  skin  become  irritated  most  readily. 

Mercurial  dermatitis  begins  as  an  erythema  which,  in  severe  cases, 
goes  on  to  an  acute  eczematous  condition  (mercurial  eczema). 

There  is  also  an  extremely  rare  dermatitis,  due  to  a  peculiar  indi- 
vidual susceptibility  to  the  internal  administration  of  mercury.  The 
eruption  is  scattered,  erythematous,  urticarial,  or  eczematous.  It  burns 
or  itches ;  in  fact,  is  a  typical  toxic  eruption.  Though  said  to  be  com- 
monest after  internal  administration,  the  only  case  I  have  seen  was  a 
sharp  urticaria  following  injection. 

The  treatment  consists  in  stopping  the  mercury  (for  a  time,  and 
then  using  it  in  small  doses),  soothing  lotions,  and  catharsis. 

Hi-effects  of  Prolonged  Mercurialization. — Mercury  can  be  given 
quite  indefinitely  in  nontoxic  doses.  But  prolonged  courses,  even 
if  only  moderately  severe,  produce  emaciation,  anemia,  and  general 
vital  deterioration,  such  as  would  ensue  upon  any  chronic  poisoning. 

If  the  medication  has  been  much  prolonged,  or  extremely  severe,  the 
patient  may  be  left  with  chronic  nephritis  or  gastro-enteritis,  from 
which  he  will  never  recover. 


INTRAMUSCULAR  INJECTIONS  833 

INTRAMUSCULAR   INJECTIONS 

Preparations  Used. — The  preparations  of  mercury  employed  for  in- 
jections are  either  sohible  or  insoluble.  The  chief  soluble  preparations 
are  the  bichlorid  and  the  biniodid. 

The  chief  insoluble  preparations  are  the  salicylate,  gray  oil,  and 
calomel. 

BicHLOKiD. — This  salt  is  used  in  1  per  cent  or  2  per  cent  solution 
with  salt  solution,  various  quantities  of  salt  being  used  by  different 
authorities.     The  following  is  an  excellent  combination: 

]^   Hydrarg.  chlorid.  corrosiv gr.  xv-xxx  ( 1-2  gm. )  ; 

Sodii  chlorid gr.  x  (0.6  gm.)  ; 

Aquae  destillat §iij  (100  c.c). 

Dose:  1  c.c.  (  '^  xv). 

BixiODiD. — The  red  iodid  of  mercury  is  employed  either  in  oily 
solution  or  in  so-called  "serum"  or  mixed  with  potassium  iodid.  It 
appears  under  various  proprietarj^  names.  I  have  employed  cypridol, 
the  Hannam's  and  Lafay's  sera.  These  preparations  are  popular  on 
the  Continent,  but  are  little  used  here.     I  prefer  the  following: 

^   Hydrarg.  biniodid oss  (2  gm.)  ; 

Potass,  iodid gr.  xv  (1  gm.)  ; 

Aquae  destillat ad  oiij  (100  c.c.) 

Among  the  soluble  preparations  the  succinamidate  (1  cgTti.  dose) 
and  the  sozoiodolate  are  well  spoken  of,  though  the  latter  is  apparently 
soon  reduced  to  biniodid. 

Salicy-late. — This  may  be  put  up  in  5  per  cent  or  10  per  cent 
strength.    The  mixture  I  employ  is : 

!l^   Hydrarg.  salicylate gT.  xlviij  (3  gm.)  ; 

Albolin  (sterilized)    §j  (30  gm.). 

Shake. — Dose:  lU  x  (0.7  c.c). 

The  salicylate  settles  to  the  bottom  and  has  to  be  distributed  by 
vigorous  shaking.  The  admixture  of  a  little  lanolin  makes  a  better  sus- 
pension but  a  thicker  mixture. 

Gray  Oil. — Gray  oil  is  an  emulsion  of  metallic  mercury. 

The  formula  I  employ  is  that  of  Laf ay : 

1^   Hydrarg.  bidestillat.^ Sijss  (10  gTa.)  ; 

Albolin oiij  ( 13.5  gm.)  ; 

Lanolin 5jss  (46.5  gm.). 

Shake. — Dose:  th,  ij-vj  (0.1  to  0.4  c.c). 
^Tbis  is  the  "dentists'  mercury." 


834  TREATMENT  OF  SYPHILIS 

Calomel. — Calomel  oil  is  made  by  pulverizing  tlie  drug,  washing 
in  boiling  alcohol,  drying  in  an  oven,  and  then  thoroughly  mixing  with 
ten  parts  of  sterilized  albolin.    Dose:  0.5  c.c. 

Method,  of  Administration. — The  soluble  salts  may  be  given  subcu- 
taneously,  but  this  method  is  unnecessarily  painful.  They  are  best 
given — and  the  insoluble  preparation  must  be  given — into  the  substance 
of  some  thick  muscle.  Injection  of  an  insoluble  preparation  subcutane- 
ously  invites  abscess  or  gangrene. 

The  site  usually  selected  for  injection  is  the  buttock.  The  pectoral 
muscles  or  the  thick  muscles  of  the  interscapular  region  or  loin  may  also 
be  utilized.  Successive  injections  are  given  on  alternating  sides,  and 
no  two  injections  should  be  put  within  an  inch  of  each  other  on  the 
same  side. 

The  best  points  for  injection  are  in  the  region  bounded  below  by  a 
line  joining  the  top  of  the  intergluteal  fold  with  the  top  of  the  trochan- 
ter; above  by  a  line  joining  the  anterior  superior  spine  with  the  sacro- 
iliac synchondrosis ;  and  limited  to  the  central  region  of  the  buttock, 
keeping  three  fingers'  breadths  away  from  the  median  line  and  from  the 
line  of  the  femoral  shaft  projected  upward. 

The  implements  are  a  sterilizable  hypodermic  syringe  (preferably 
all  glass,  as  metal  instruments  are  amalgamated  by  mercury),  and  a 
needle  two  inches  long  and  of  ample  caliber;  for  very  stout  persons 
the  needle  should  be  two  and  a  half  inches  long. 

Technic. — Boil  the  implements,  wash  your  hands,  and,  making  the 
patient  lie  upon  his  face,  rub  the  buttock  well  with  alcohol. 

Then,  having  filled  the  syringe  and  attached  the  needle,  plunge  this 
up  to  the  hilt  in  the  appointed  spot  and  inject.  Then  withdraw  the 
needle  and  briskly  rub  the  subcutaneous  fat  so  as  to  obliterate  its  track. 

Bleeding  is  readily  controlled  by  pressure  and  adhesive  plaster. 

Dosage. — It  will  be  found  that  any  of  these  preparations  may  be 
given  to  certain  patients  in  very  high  doses. 

But  equally  good  results,  nay,  better  ones,  may  be  obtained  by  the 
ordinary  doses  given  above,  and  an  apparent  toleration  on  the  part  of 
the  patient  should  never  tempt  us  to  excessive  hypodermic  medication. 
I  know  no  rule  more  important  than  this,  for  excessive  medication  by 
injection  produces  a  distinctly  cumulative  effect.  The  mercury  con- 
tinues to  be  absorbed  for  many  days  after  its  injection,  and  I  have 
several  times  seen  severe  and  prolonged  salivation  begin  in  the  second 
or  third  week  folloiving  cessation  of  treatment  by  insoluble  injections, 
and  continue  for  many  weeks  thereafter. 

The  choice  between  soluble  and  insoluble  injections  is  largely  a  mat- 
ter of  taste.  Both  have  their  champions  for  the  routine  as  well  as  for 
the  symptomatic  treatment  of  syphilis.  None  of  these  injections  is 
absolutely  painless  (despite  what  their  votaries  say  to  the  contrary), 


INTRAMUSCULAR  INJECTIONS  835 

and,  since  soluble  injections  have  to  be  given  every  day  for  a  "course" 
of  ten  to  thirty  injections,  the  pain  caused  by  them  is  cumulative,  and  in 
the  end  may  be  less  tolerable  than  the  more  severe  but  less  often  re- 
peated pain  from  insoluble  injections. 

A  more  important  distinction  is  this :  Insoluble  injections  are  the 
more  efficient,  and,  since  efficiency  is  the  one  claim  made  in  favor  of  in- 
jections, this  fact  is  gradually  forcing  insoluble  injections  to  the  fore. 

On  the  other  hand,  we  have  to  consider  the  relatively  grave  accidents 
that  may  result  from  insoluble  injections. 

Disadvantages  of  Injections. — Soluble. — The  disadvantages  of 
soluble  injections  are  the  cumulative  pain,  the  relative  inefficiency,  and 
the  necessity  for  daily  visits  to  the  physician. 

liS^soLijBLE. — The  disadvantages  of  insoluble  injections  are  general 
and  local. 

The  general  disadvantages  of  insoluble  injections  are  poisoning  and 
embolism. 

Acute  mercurial  poisoning  may  follow  within  twenty-four  hours  of 
a  single  injection  of  mercury.  It  is  characterized  by  cramps,  explosive 
diarrhea,  depression  of  spirits,  even  fever ;  it  may  last  several  days.  If 
the  usual  doses  are  employed  such  an  attack  follows  the  first  injection 
once  in  every  thirty  or  forty  cases.  It  is  not  prohibitive.  Lessen  the 
dose  at  the  next  injection,  and  thereafter  return  to  the  full  dose. 

Grave  salivation  follows  any  overdose  with  mercury,  but  that  fol- 
lowing injections  of  insoluble  mercury  has  two  very  annoying  charac- 
teristics :    It  is  slow  to  appear  and  slow  to  disappear. 

Embolism. — The  embolism  is  almost  always  pulmonary;  its  symp- 
toms may  appear  the  day  after  injection,  though  they  usually  follow  it 
immediately. 

After  a  more  or  less  marked  premonitory  stag3  of  slight  fever  and 
malaise,  the  attack  begins  with  a  sharp  pain  in  the  side,  which  inter- 
feres gTeatly  with  respiration.  The  temperature  and  pulse  rise;  the 
patient  is  much  prostrated.  The  physical  signs  are  those  of  a  circum- 
scribed pneumonia.     The  whole  attack  lasts  from  a  few  hours  to  a  week. 

The  frequency  of  embolism  is  estimated  at  about  one  in  a  thousand 
injections.  I  have  had  but  five  in  my  practice  and  my  father  one ;  this 
in  several  thousand  injections.^  One  or  two  fatal  cases  of  mercurial 
embolism  have  been  reported. 

The  local  disadvantages  of  insoluble  injections  are  pain,  induration, 
abscess,  sloughing. 

*  It  has  been  alleged  that  the  danger  of  embolism  may  be  averted  by  disen- 
gaging the  needle  before  injecting  and  noting  whether  the  free  flow  of  blood 
from  it  shows  its  point  to  be  in  a  vein.  But  I  have  deliberately  tested  this 
method  in  the  clinic,  and  got  no  embolism  from  six  cases  that  bled,  though  we 
did  get  an  embolism   from  one  that  bled   not  a  drop. 


836  TREATMENT  OF  SYPHILIS 

The  pain  varies  greatly.     Soluble  injections  are  painful  for  one  to 

three  days;  during  this  time  they  may  cause  agony.  Insoluble  injec- 
tions give  no  immediate  pain  unless  a  nerve  is  actually  punctured  by 
the  needle;  but  in  from  six  to  twenty-four  hours  the  spot  begins  to  ache, 
and  this  ache  increases  for  a  day  or  two  longer,  then  gTa dually  dimin- 
ishes, but  may  last  ten  days  or  more. 

The  first  injection  is  likely  to  hurt  more  than  subsequent  ones,  but 
no  two  of  them  are  alike.  One  may  set  up  an  intense  sciatica,  lasting 
a  week,  and  the  next  one  be  almost  painless.  Some  persons  feel  the 
pain  much  more  than  others.  Indeed,  it  is  practically  prohibitive  in 
certain  cases. 

I^iduratioiis  may  occur  even  from  insoluble  injections.  I  have  had 
a  patient  come  to  me  with  both  buttocks  a  solid  indurated  mass  from 
injections  of  bichlorid. 

Abscess  and  gdngrene  are  due  to  dirt  or  carelessness.  iSTeither  ac- 
cident has  occurred  in  my  practice. 


INUNCTION 

Preparations  Employed — The  official  Hue  ointment  (ung.  hydrar- 
gyri)  can  be  improved  by  the  substitution  of  one  of  the  proprietary  oint- 
ment bases.  These  are  less  greasy  and  odoriferous.  Put  up  in  capsules 
(one  for  each  rub)  they  are  convenient  to  carry  about. 

Another  new  preparation  is  calomelol  ointment,  white  in  color,  in 
graduated  glass  tubes,  two  of  the  "marks"  to  be  used  for  each  rub.  It 
is  cleaner  than  the  blue  ointment,  and  seems  to  be  about  as  efficient  and 
somewhat  less  irritating. 

The  Technic. — The  best  method  is  that  employed  at  the  Hot  Springs. 
The  patient  takes  a  hot  soap-and-water  bath,  is  well  rubbed  do^^Ti  with 
alcohol,  and  then  is  ready  for  his  inunction.  He  sits  astraddle  a  chair 
with  his  face  toward  the  back,  his  arms  folded  upon  it  and  his  chin 
resting  upon  his  arms.  An  attendant  now  rubs  in  broadly  and  with  a 
vigorous  circular  motion  of  the  hand  over  the  entire  back  a  given  quan- 
tity of  mercurial  ointment,  generally  one  dram  at  a  rub.  The  friction 
continues  for  twenty  minutes.  (To  prevent  mercurialization  the  fric- 
tioner  may  protect  his  hand  with  a  rubber  glove.)  The  ointment  thus 
rubbed  in  is  left  upon  the  back,  and  the  patient  puts  on  first  a  thin  gauze 
undershirt  (which  he  wears  a  week  as  a  "mercurial"  shirt),  and  over 
this  his  ordinary  undershirt  and  customary  clothing.  On  the  following 
day  the  patient  takes  another  hot  soap-and-water  bath,  is  thoroughly 
wai?hed,  rubbed  with  alcohol,  and  then  takes  another  friction  as  on  the 
previous  day,  resuming  his  mercurial  shirt. 

In  case  the  patient  has  to  do  his  own  rubbing  he  cannot  reach  his 


HYGIENE  837 

back,  and  as  no  other  part  of  the  body  is  covered  with  skin  sufficiently 
thick  to  bear  daily  rubs,  he  is  obliged  to  shift  from  place  to  place.  The 
hot  bath,  the  alcohol  rub,  and  the  mercurial  shirt  are  employed  as  in  the 
above-described  system,  and  the  rubs  are  made  in  the  following  regions 
on  successive  days: 

1.  Right  arm  and  forearm,  internal  aspect. 

2.  Left  ann  and  forearm,  internal  aspect. 

3.  Eight  thigh. 

4.  Left  thigh. 

5.  Right  side  of  thorax  and  loin. 

6.  Left  side  of  thorax  and  loin. 

7.  Abdomen. 

The  purpose  in  thus  distributing  the  course  is  to  make  it  occupy  an 
even  week.     Hairy  subjects  may  have  to  modify  the  plan. 

The  oi*Qtment  must  be  rubbed  into  the  skin  until  every  bit  of  greasi- 
ness  has  disappeared.  This  takes  about  twenty  minutes,  and  is  a  duty 
the  patient  is  inclined  to  shirk. 

Merits  of  Inunctions. — In  efficacy  inunction  ranks  below  injection. 
In  convenience  it  may  rank  higher,  in  that  it  can  be  performed  by  the 
patient  himself.  But  the  dosage  is  uncertain,  for  we  do  not  know  how 
much  mercury  is  absorbed  by  the  skin  (indeed,  it  may  not  be  absorbed 
at  all  ^ ) ,  and  very  few  patients  rub  in  the  ointment  thoroughly. 

But  the  chief  objection  to  inunction  comes  from  the  patient.  The 
treatment  is  dirty  and  disgusting;  it  often  irritates  the  skin,  and  may 
even  provoke  a  local  eczema. 

For  these  reasons  a  patient  when  asked  to  choose  between  inunction 
and  injection  almost  invariably  selects  the  latter.  And  unless  he  is 
oversensitive  to  injections,  I  much  prefer  he  should. 


THE  lODIDS 

Salvarsan  has  eliminated  potassium  iodid  from  the  treatment  of 
syphilis.  The  drug  is  still  employed,  but  everything  that  it  can  do  in 
the  relief  of  pain  and  in  the  conquest  of  tertiary  lesions  of  syphilis  is  so 
much  better  done  by  salvarsan  that  its  effects  and  defects  scarcely  seem 
worth  enumerating. 

HYGIENE 

The  hygiene  of  the  syphilitic  is  precisely  that  of  the  tuberculous 
patient.  Each  is  a  chronic  disease  controllable  chiefly  by  virtue  of  the 
patient's  own  reaction.     That  we  possess  an  array  of  specific  drugs 

^Cf.  Ha7,   Jour.  A.  M.  A.,   1909,  liii,  674, 


838  TREATMENT  OF  SYPHILIS 

for  the  treatment  of  syphilis  is  no  excuse  for  utterly  neglecting  the 
patient's  health.  Especially  brilliant  results  may  be  obtained  in  the 
treatment  of  syphilis  by  taking  advantage  of  the  intervals  between 
courses  of  the  specific  drugs  to  administer  "milk  and  sunshine."  The 
syphilitic  infant  is  never  overweight.  The  tabetic  is  always  thin.  The 
prognosis  of  syphilis  may  sometimes  be  as  accurately  estimated  in 
terms  of  pounds  gained  or  lost  as  in  terms  of  the  Wassermann  reaction. 


CHAPTEE   LXXXVI 

THE  INITIAL  LESION 

The  initial  lesion  (primary  lesion)  of  syphilis  consists  of  the 
chancre  and  the  adjacent  adenitis.  It  must  not  be  forgotten  that  the  in- 
flamed lymph  glands  form  as  essential  and  characteristic  a  part  of  the 
initial  lesion  as  does  the  chancre  itself. 

THE  CHANCRE 

The  chancre  is  an  eroded  or  ulcerated,  painless  neoplasm,  arising 
at  the  site  of  syphilitic  inoculation. 

The  chancre  is  primarily  a  neoplasm.  By  bearing  this  in  mind  we 
distinguish  it  instinctively  from  chancroid,  which  is  primarily  an  ulcer. 
The  one  is  a  lump,  the  other  a  hole. 

This  neoplasm  is  commonly  called  the  induration.  The  induration 
may  be  very  extensive ;  it  may  form  a  large  hard  lump,  projecting  mark- 
edly above  the  surrounding  tissues  and  having  a  diameter  of  perhaps  an 
inch.  But  usually  (in  eight  cases  out  of  ten)  it  is  small — one  might 
almost  say  minute — and  instead  of  projecting  above  the  integument  it 
is  embedded  in  it.  Thus,  it  may  be  felt  rather  than  seen,  and  in  ap- 
pearance is  rather  insignificant  than  impressive. 

The  surface  of  this  insignificant  neoplasm  is  almost  always  eroded 
and  moist,  but  it  may  be  ulcerated,  or  it  may  be  covered  by  an  unbroken 
reddened  integument. 

It  is  peculiarly  hard  and  elastic,  as  though  a  piece  of  cardboard 
were  embedded  in  the  integument.  In  order  to  appreciate  this  one 
must  pick  it  up  from  the  surrounding  tissues  and  palpate  it  from  side 
to  side. 

Pathology. — The  chancre  has  the  general  characteristics  of  syphi- 
loma. We  find  in  a  connective-tissue  framework  a  mass  of  plasma  cells, 
leukocytes — all  the  elements  of  an  acute  localized  exudative  inflamma- 
tion. The  vessels,  especially  the  arteries,  are  infiltrated,  irregularly 
thickened,  and  occluded  by  the  characteristic  "coat-sleeve"  infiltration. 
The  surface  of  growth  is  more  or  less  necrotic,  whence  the  erosion  or 
ulceration.  Proper  staining  shows  spirochetes  in  the  substance  of  the 
chancre. 

839 


840  THE  INITIAL  LESION 

This  inflammation  diminishes  insensibly  toward  the  border  of  the 
induration  and  extends  into  the  surrounding  tissue  far  beyond  the 
apparent  limits  of  the  growth.  The  infiltrations  in  the  vessel  walls,  in 
particular,  extend  beyond  the  palpable  seat  of  the  disease.  Yet  the 
depth  of  the  chancre  is  almost  nil.  It  occupies  chiefly  the  epidermal 
layer  of  the  skin,  encroaching  but  little  on  the  true  derma  and  the  sub- 
jacent tissue.    Hence  it  leaves  no  scar. 

Multiple  Chancres. — The  most  striking  characteristic  of  chancre  is 
its  insignificance;  next  in  order  of  importance  is  its  uniqueness.  Yet 
too  much  stress  may  be  laid  upon  this.  The  chancre  is  usually  single, 
to  be  sure,  yet  Papagaey,^  who  collected  14,004  reported  cases,  found 
that  in  from  25  per  cent  to  33  per  cent  the  chancres  were  multiple.  This 
confirms  other  Continental  statistics ;  yet  multiple  chancres  are  cer- 
tainly much  fewer  in  my  practice.  My  records  show  only  56  among 
549  case.'",  examined — i.  e.,  1  in  10. 

But  whether  1  in  10  or  1  in  3,  the  multiple  chancre  must  be 
counted  with,  and  it  is  a  grave  clinical  error  to  insist  on  the  uniqueness 
of  cJiancre  as  a  diagnostic  factor. 

The  number  of  multiple  chancres  is  2  in  78  per  cent  of  cases  (Pa- 
pagaey).  My  father  has  recorded  1  case  of  11  and  1  of  12  chancres 
(4:  on  the  left  breast,  8  on  the  right),  rournier  has  seen  a  patient  with 
23  (7  on  the  left  breast,  16  on  the  right). 

The  location  of  multiple  chancres  is  almost  exclusively  genital. 
Only  2  per  cent  of  extragenital  chancres  are  multiple  (Fournier). 
Chancres  of  the  breast  are  quite  frequently  multiple. 

The  existence  of  multiple  chancres  brings  up  the  question,  When 
does  syphilitic  immunity  begin  ?     Is  reinoculation  possible  ? 

Although  in  many  instances  the  several  inoculations  are  indubitably 
simultaneous,  in  others  they  doubtless  succeed  one  another,  perhaps 
after  an  interval  of  several  days.  Indeed,  Queyrat  ^  has  proven  that 
it  is  sometimes  possible  to  auto-inoculate  chancre  if  the  inoculation  is 
performed  before  the  lesion  is  ten  days  old,  and  experimental  inocula- 
tion bears  this  out. 

Types  of  Chancre — The  three  chief  types  of  chancre  are: 

1.  The  eroded  chancre. 

2.  The  ulcerated  chancre. 

3.  The  indurated  papule. 

The  Ekoded  Chancee. — From  60  to  80  per  cent  of  chancres  as- 
sume this  form.  It  is  most  characteristically  exemplified  by  chancres 
within  the  preputial  cavity. 

The  induration  is  rounded,  circumscribed,  and  thin,  sometimes  so 
thin  as  to  be  scarcely  perceptible  except  to  the  most  delicate  touch 

*Lo  syphilis,   1906,   iv,   64. 

^Bull.  de  la  soc.  Franc,  de  derm,  et  de  sypli.,  1906,  vol.  xvii,  p.  66. 


THE  CHANCRE 


841 


(parclimeiit  chancre).     Exceptionally  tlie  parclimcnt  chancre  ulcerates 
deeply. 

Its  color  is  usually  a  dark,  vinous,  or  "raw-meat"  red.  Earely  it 
is  of  a  dusty  gray  color  (the  color  of  lard).  It  may  be  covered  with 
little  petechiae. 

Its  surface  is  usually  flat.  It  may  be  a  little  elevated  above  the 
surrounding  integaiment,  or  a  trifle  sunken  below  it,  or  surrounded  by 
a  slightly  elevated  ring  of  induration. 

The  eroded  surface  is  smooth  and  polislied.    It  emits  a  slight  sero- 
purulent  discharge.     It  may  be  cov- 
ered by  a  crust  or  a  false  membrane 
(from  infection  by  skin  cocci). 

The  Ulcerated  Citaivcre. — • 
This  is  the  type  of  chancre  described 
by  Hunter,  and  to  it  the  title  "hun- 
terian  chancre"  is,  therefore,  pe- 
culiarly applicable.  It  is  far  less 
common  than  the  eroded  chancre. 

It  has  a  relatively  large  in- 
durated base  topped  by  a  distinct  ul- 
cer. The  ulcer  is  due  to  extensive 
necrosis,  and  the  necrosis  is  propor- 
tional to  the  interference  with  circu- 
lation; thus  the  thinner  induration 
forms  an  eroded  chancre,  while  the 
more  nodular  mass  ulcerates. 

The  ulcer  extends  into  the  true 
derma.  It$  edges  are  sloping  (not 
imdermined)  and  give  the  sore  a  sort 

of  funnel  shape ;  the  base  is  granulating  and  may  be  covered  by  a  false 
membrane ;  the  discharge  is  slight  and  serosanguinolent. 

The  clinical  picture  of  ulcerated  chancre  is  that  of  a  neoplasm  eaten 
out  by  an  ulcer,  not  that  of  an  ulcer  surrounded  by  an  inflammatory 
ring.  The  neoplasm  may  be  embedded  within  the  skin ;  but  pick  it  up, 
and  you  will  realize  that  it  is  a  distinct  lump  with  an  ulcer  in  the 
center. 

The  Indurated  Papule. — This  is  the  rarest  type  of  chancre.  It 
occurs  usually  in  situations  where  the  integument  is  so  dense  and  thick 
as  to  prevent  very  extensive  development  of  the  neoplasm.  The  indura- 
tion consequently  remains  a  small,  dark-red,  flat  papule.  As  it  begins 
to  heal  the  surface  becomes  scaly. 

Exceptional  Varieties.— -The  induration  may  be  so  slight  as  to  be 
clinically  imperceptible.  Fournier  noted  this  absence  of .  induration 
7  times  in  300  cases. 


Fig.  192. — Large  Ulcerated  Hunterian 
Chancre.     (Kaposi.) 


842  THE  INITIAL  LESION 

As  a  result  the  lesion  appears  to  be  either  •. 

1.  A  superficial  herpetiform  ulceration  or  group  of  ulcerations  (her- 
petiform  chancre),  or 

2.  A  grayish  or  silver-white  spot  of  thickened  epithelium.  This  is 
seen  only  on  the  glans  penis. 

Both  these  types  are  extremely  rare. 

On  the  other  hand,  the  induration  may  be  very  extensive^  and 
extend  far  beyond  the  ulceration. 

Complications  of  Chancre. — The  chief  complications  of  chancre  are : 

1.  Lymphangitis  and  edema. 

2.  Chancroid  (mixed  sore). 

3.  Simple  inflammation. 

4.  Phagedena  (gangrene). 

5.  Transformation  into  a  mucous  papule. 

6.  Vegetations. 

Lymphangitis. — Corded  lymphatics,  running  from  the  chancre  to 
the  adjacent  glands  (e.  g.,  along  the  dorsum  of  the  penis),  are  not 
often  seen. 

But  in  certain  localities,  such  as  the  prepuce  and  the  labia  majora, 
a  great  mass  of  lymphatic  induration  may  surround  the  chancre,  or 
small  similar  masses  may  lie  adjacent.  Such  a  complication  obstructs 
the  lymphatic  flow  and  causes  considerable  edema.  It  is  sometimes 
spoken  of  as  indurative  edema. 

"Mixed"  Sore. — As  chancroid  itself  is  rare  among  the  upper 
classes,  so  is  the  mixed  sore,  the  combination  of  chancroid  and  chancre. 
Among  the  chancres  seen  in  the  dispensary,  however,  fully  one-third 
are  "mixed  sores." 

The  possible  combinations  of  chancre  and  chancroid  are  three : 

1.  The  chancroid  may  appear,  flourish,  and  be  cured,  and  from  its 
remains  the  chancre  may  arise. 

2.  The  chancroid  may  overlap  and  overshadow  the  chancre,  so  that 
the  latter  is  suspected  only  from  the  induration  remaining  after  the 
sore  heals,  or  proven  by  the  appearance  of  secondary  syphilitic  lesions, 
or  a  positive  Wassermann  reaction. 

3.  A  true  chancre  may  become  chancroidal. 

Of  the  three  types,  the  second  is  the  one  commonly  observed.  The 
presence  of  chancre  is  not  even  suspected  until  the  chancroid  in  healing- 
begins  to  take  on  a  suspicious  hardness,  or  until  a  roseola  breaks  out  all 
over  the  patient.  While  the  patient  has  a7i  active  chancroid^  therefore, 
one  can  never  assure  him  he  has  not  true  chancre. 

Inflamed  Chancre. — The  friction  of  clothes,  or  any  other  form  of 
trauma,  may  so  irritate  the  chancre  that  it  becomes  acutely  inflamed  : 
yet  this  is  unusual.  As  a  rule,  the  pyogenic  microbes  have  no  efl'ect 
upon  chancre  beyond  encouraging  ulceration. 


THE  ADENITIS  OF  CHANCRE  843 

Gangrenous  and  Phagedenic  Chancre. — The  obstruction  to  cir- 
culation in  the  indurated  base  of  a  chancre  is  habitually  sufficient  to 
excite  desquamation  and  exudation  from  its  surface.  Exceptionally, 
it  is  so  marked  as  to  cause  gangrene  of  the  dermis.  Such  a  complica- 
tion is  of  no  great  importance.  Phagedena  is  far  rarer.  Indeed,  the 
occurrence  of  phagedena  is  presumptive  evidence  that  the  sore  is  noi 
charicre.     It  is  probably  gumma. 

Transformation  into  a  Mucous  Papule. — Chancre  upon  the 
mucous  membrane  or  between  moist  folds  of  skin  may,  at  the  time  of  the 
first,  general,  secondary  outbreak,  become  a  typical  mucous  papule. 
The  fact  requires  no  further  comment. 

Vegetations. — Soft  warts  may  surround  the  chancre.  Their  pres- 
ence is  accidental,  and  can  scarcely  be  called  a  complication. 

Duration. — The  chancre  usually  lasts  four  to  six  weeks,  though  some 
trace  of  induration  may  remain  many  months. 

Reinduration  of  the  chancre,  which  simply  means  recurrence  of 
syphilitic  inflammation  in  a  chancre  partially  or  wholly  cicatrized,  may 
prolong  its  duration  indefinitely. 

Fournier  relates  that  he  has  seen  a  chancre  run  its  whole  course  in 
two  weeks.  This  must  be  about  the  minimum.  Yet  patients  will  often 
say  that  their  chancres  only  lasted  a  few  days,  for  they  are  careless 
observers.  Their  testimony  merely  bears  witness  to  the  clinical  in- 
sigTiificance  and  painlessness  of  this  lesion  so  fraught  with  grave  con- 
sequences. 

Diagnosis.- — During  the  first  week  of  a  chancre  spirochetes  may 
readily  be  found  in  its  secretion  (p.  803).  During  the  ensuing  weeks 
they  become  less  numerous  here  but  may  often  be  obtained  by  aspira- 
tion of  the  inguinal  glands.  The  Wassermann  reaction  often  becomes 
positive  in  the  second  or  third  week,  almost  always  in  the  fifth  week, 
and  always  between  the  eighth  and  tile  tenth  week  following  the  appear- 
ance of  the  chancre. 

Treatment. — A  daily  wash  with  warm  water,  protection  from  fric- 
tion of  the  clothes,  and  the  application  of  any  simple  dusting  powder  is 
all  the  treatment  the  chancre  needs. 

But  the  disease  requires  instant  and  energetic  specific  treatment. 


THE  ADENITIS  OF  CHANCRE 

Syphilitic  inflammation  of  the  group  of  lymph  glands  adjacent  to 
the  chancre  is  part  of  the  initial  lesion.  It  is  as  constant  and  typical  as 
the  chancre  itself.  Indeed,  Fournier  failed  to  find  it  only  thrice  in 
5,000  cases.  It  appears  in  the  second  week  after  the  outbreak  of  the 
sore. 


844  THE  INITIAL  LESION 

Inguinal  adenitis  may  be  bilateral  or  unilateral ;  if  tbe  latter,  it  is 
usually  on  the  side  corresponding  to  the  chancre.  Exceptionally  the 
lymphatics  so  anastomose  that  the  adenitis  is  on  the  opposite  side 
(crossed  bubo).    As  a  rule,  however,  both  sides  are  affected. 

Symptoms. — The  adenitis  appears  in  the  second  week  after  the 
appearance  of  the  chancre,  usually  on  or  about  the  tenth  day.  It  reaches 
maturity  in  two  or  three  days,  and  presents  the  following  character- 
istics: multiplicity,  moderate  size,  absence  of  peri-adenitis  and  of  all 
acute  inflammation,  hardness,  slow  resolution. 

Multiplicity. — There  is  always  a  group  of  glands  involved;  in- 
deed, inguinal  adenitis  usually  shows  involvement  of  a  group  in  each 
groin,  but  the  one  rather  more  enlarged  than  the  other. 

This  group,  or  pleiad,  as  Ricord  appropriately  termed  it,  is  made  up 
of  one  (rarely  more)  large  gland  surrounded  by  a  group  of  lesser  ones 
(clinically  the  large  node  often  predominates  the  scene,  the  lesser  ones 
being  scarcely  discernible). 

Size. — The  larger  gland  scarcely  attains  the  size  of  a  cherry  and 
may  be  much  smaller ;  the  lesser  ones  are  the  size  of  peas. 

Absence  of  Inflammation. — Unless  there  is  mixed  infection  the 
glands  are  neither  painful  nor  tender.  They  are  freely  movable  be- 
neath the  skin,  upon  the  subjacent  parts,  and  upon  one  another.^  The 
skin  over  them  is  not  discolored;  they  do  not  suppurate.  This  com- 
plete absence  of  peri-adenitis  is  one  of  their  most  striking  characteristics. 

Hardness. — "The  hardness  of  the  glands  is  the  hardness  of  the 
chancre;"  such  is  the  routine  statement.  The  clinical  facts  do  not  quite 
bear  it  out.  Though  the  glands  may  be  as  hard  as  the  chancre,  and 
when  so  are  typical,  in  the  larger  number  of  cases  they  are  distinctly 
more  elastic. 

Slow  Resolution. — The  great  virtue  of  syphilitic  bubo  is  that  it 
persists  many  weeks  after  the  chancre  has  disappeared  and  may  lead,  to 
the  discovery  of  the  scar  of  a  healed  chancre.  It  usually  persists  three 
months. 

Unusvial  Varieties — ^The  bubo  may  be  abnormal,  inflamed,  or 
"mixed." 

Abnormal  Bubo. — Exceptionally  the  bubo  consists  of  a  single  very 
large  gland,  or  the  large  gland  is  altogether  lacking. 

Inflamed  Bubo. — Inflamed  bubo  is  much  more  common  than  in- 
flamed chancre.  The  pyogenic  bacteria  multiply  upon  the  chancre  and 
from  it  enter  the  lymph  current,  yet  may  not  cause  much  local  irrita- 
tion. The  common  clinical  causes  of  inflamed  bubo  are  genital  filth  and 
cohabitation. 

The  bubo  of  labial  or  buccal  chancre  is  habitually  a  large,  tender, 
inflamed  mass. 

^  Unless   they   are  inflamed,  in  which   case   they   adhere  to   one   another. 


THE  ADENITIS  OP  CHANCRE  845 

"Mixed"  Bubo. — Syphilitic  adenitis  may  be  complicated  by  chan- 
croid or  by  tuberculosis. 

Chancroid  and  chancre  combine  to  make  a  "mixed"  sore  and  a 
"mixed"  bubo.  In  both  instances  the  characteristics  of  the  chancroid 
lesion  overshadow  the  other. 

Tuberculosyphilitic  glands  I  have  never  seen.  They  are  said  to 
assume  the  tuberculous  type. 

Diagnosis. — The  typical  group  of  one  large  uninflamed  gland  sur- 
rounded by  a  lot  of  little  ones — all  of  them  hard,  insensitive,  and  not 
adherent — is  so  unmistakable  that  a  discussion  of  its  differentiating 
characteristics  is  all  but  superfluous. 

Certain  varieties  of  herpes  or  balanitis  excite  a  bubo  quite  similar 
to  that  of  syphilis ;  but  the  exciting  lesion  is  so  dissimilar  that  a  mistake 
is  scarcely  possible. 

The  insensitive,  hard,  movable  glands  of  syphilis  can  scarcely  be 
confused  with  the  inflamed,  tender,  adherent  nodes  of  chancroid; 
though,  as  we  have  already  said,  the  latter  may  conceal  the  former. 

The  diagnosis  is  certified  by  the  discovery  of  spirochetes  or  by  the 
Wassermann  reaction. 


CHAPTER   LXXXYII 

SYPHILIS  OF  THE  SKIN:  GENERAL  CHARACTERISTICS;  SECOND- 
ARY   SYPHILIDS— SECONDARY    SYPHILIS    OF    THE 
MUCOUS  MEMBRANE 

SYPHILIS  OF  THE  SKIN 

Syphilitic  skin  lesions  are  marked  by  certain  general  characteris- 
tics that  serve  to  identify  them  from  other  similar  nonsyphilitic  lesions. 
The  diagnosis  of  any  given  syphilid  is  founded  largely  on  these  charac- 
teristics. 

GENERAL  CLINICAL  CHARACTERISTICS 

1.  Progressive  development. 

2.  Polymorphism. 

3.  Absence  of  local  or  general  inflammatory  reaction. 

4.  Absence  of  pain  and  itching. 

5.  Peculiar  raw-ham  color. 

6.  Rounded  form. 

7.  Scales  white,   superficial,  nonadherent. 

8.  Crusts  greenish  or  black,  thick,  irregular,  adherent. 

9.  Ulcerations  rounded  or  circinate,  with  abrupt  edges,  sanious  se- 
cretion, and  sluggish  base. 

10.  Scars  round,  depressed,  thin,  nonadherent,  smooth,  often  pig- 
mented. 

11.  Early  eruptions  disseminated  and  profuse,  later  ones  asym- 
metrical and  grouped. 

Progressive  Development. — With  various  degrees  of  speed,  but,  as  a 
rule,  slowly  and  gradually,  the  eruption  spreads.  The  superficial  gen- 
eral eruption  spreads  by  the  appearance  of  new  lesions ;  the  later  single 
lesions  by  encroaching  on  the  surrounding  tissues. 

Polymorphism — The  early,  general  eruption  develops  progressively 
in  type  as  well  as  in  multiplicity  of  lesions.  Thus  a  general,  papular 
eruption  a  week  old  may  show  macules,  papules,  tubercles,  vesicles,  pus- 
tules, and  minute  ulcers  irregularly  intermingled.  Such  is  polymor- 
phism.    It  is  all  but  pathognomonic  of  syphilis. 

The  later  the  eruption  the  less  polymorphic  it  is  likely  to  be. 

Absence  of  Inflammation — Fever  very  rarely  accompanies  a  syphi- 

846 


GENERAL  CLINICAL  CHARACTERISTICS  847 

litic  eruption.  Exceptions,  chiefly  due  to  absorption  from  mixed  infec- 
tion of  a  pustular  syphilid,  are  so  few  as  to  be  negligible. 

ISTeither  is  tenderness,  heat,  nor  inflammatory  congestion  discernible 
in  the  lesion  itself. 

Absence  of  Pain  and  Itching — The  syphilitic  lesion  as  such  is  pain- 
less. In  those  exceptional  instances  (and  they  are  singularly  rare)  of 
mixed  infection  with  the  ordinary  pyogenic  microbes,  the  pain  is  due  to 
the  adventitious  inflammation. 

Moreover,  the  syphilid  does  not  itch.  A  little  tingling  may  accom- 
pany the  relatively  rapid  development  of  a  diffuse  exanthem,  but  even 
this  is  rare  and  does  not  amount  to  a  real  itch. 

Peculiar  Color — The  color  of  the  syphilids  is  not  a  frank,  inflam- 
matory red,  but  a  vinous,  empurpled  redness,  resembling,  when  well 
marked,  the  raw  meat  of  ham.  This  color  is  found  also  in  many  of  the 
gouty,  papular  eruptions  and  in  psoriasis,  rarely  in  other  eruptions. 
The  color  of  the  syphilids  passes  by  pigmentation  from  this  dusky  red 
into  a  yellowish  copper  color,  and  sometimes  by  a  deep  pigmentation 
to  brown  or  black,  the  skin  around  the  lesion  (areola)  being  usually 
also  pigmented  to  a  certain  extent.  This  pigmentary  coloration  some- 
times lingers  for  years,  but  usually  clears  off  after  a  few  months,  dis- 
appearing first  centrally,  then  peripherally.  Finally,  the  spot  becomes 
brilliantly  white. 

Eounded  Form — Every  syphilid  is  composed  of  circular  lesions.  If 
discrete,  as  in  most  of  the  earlier  eruptions,  the  individual  lesions  are 
manifestly  round.  But  many  of  the  later  lesions  are  confluent.  Either 
because  the  lesions  begin  so  close  together  or  because  in  spreading 
they  invade  the  same  territory,  the  resultant  lesion  is  a  composite  one, 
and  this  may  show  a  circinate,  polycyclic  edge,  which  is  very  charac- 
teristic. 

Moreover,  although  the  disposition  of  the  first  general  eruptions  is 
diffuse  and  irregular  (though  symmetrical),  the  lesions  composing  later 
eruptions  are  often  distributed  in  circles  or  in  segments  of  circles. 

Finally,  certain  of  the  more  chronic  syphilids  as  they  progress 
extend  in  every  direction  toward  the  periphery,  healing  at  the  same 
time  in  the  center.  Hence  result  lesions  of  a  circular  or  circinate 
or  horseshoe  shape  quite  pathognomonic.  Such  eruptions  are  called 
serpiginous. 

The  Scale. — The  scales  on  the  cicatrices  and  on  the  patches  of  scaly, 
syphilitic  eruptions  are  thin,  white,  nonadherent,  lamellar;  they  are 
very  different  from  the  dense,  thick,  imbricated,  adherent  scales  of 
psoriasis. 

The  Crust. — The  scabs  fonned  on  syphilitic  ulcerative,  rupial,  and 
pustular  lesions  are  rough  and  adherent,  dark  brown,  or  greenish  black. 
sometimes  loosened  by  an  imderlying  accumulation  of  pus,  but  more 


848  SYPHILIS  OF  THE  SKIN 

often  seemingly  set  into  the  skin,  and  tiglitly  adherent.  They  may  be 
of  light  color  over  secondary  pustular  lesions,  but  whether  light  or 
dark,  the  green  hue  is  rarely  totally  absent  and  is  often  brilliantly 
marked. 

The  Ulceration — With  the  exception  of  the  chancre  and  of  the  ul- 
cerated mucous  papule  (both  of  which  may  vegetate  and  are  usually 
elevated  rather  than  depressed),  the  ulcerations  of  syphilis  resemble 
chronic,  indolent  ulcers.  They  are  rounded  or  oval,  with  abrupt  edges 
cut  away  like  those  of  a  chancroid ;  the  base  is  covered  with  yellowish, 
false  membrane,  sometimes  bluish,  like  boiled  sago.  The  edges  and 
base  of  the  ulcer  are  usually  hard,  and  the  former  generally,  but  not 
invariably,  firmly  adherent  and  not  undermined,  as  in  the  ulcerations  of 
tuberculosis.  These  ulcers  do  not  bleed  easily,  are  generally  atonic  and 
.  sluggish,  and  usually  entirely  painless.  Apparent  exceptions  to  the  rule 
in  regard  to  pain  are  often  due  to  the  dependent  position  or  other  cause 
calculated  to  excite  inflammation,  or  to  the  situation  of  the  ulcer  over 
a  bone,  the  periosteum  of  which  is  inflamed  and  painful. 

The  Scar — The  cicatrices  of  such  syphilitic  lesions  as  have  de- 
stroyed tissue  (i.  e.,  tertiary  lesions),  whether  there  has  been  surface 
ulceration  or  not,  are  rounded,  very  thin,^  depressed,  smooth,  shining, 
and  nonadherent.  They  are  often  at  first  uniformly  pigmented  of  a 
dark-brown  hue  (nearly  black  in  brunettes).  This  pigment  clears  off 
from  the  center  to  the  circumference  until  only  a  dark  border  is  left, 
which  sometimes  lasts  for  years,  but  finally  the  whole  cicatrix  acquires 
an  almost  pearly  whiteness  (though  the  pigTiaentation  may  persist 
indefinitely). 

General  Clinical  Chakactekistics  of  Secondary  and  Tertiary 

Syphilids 

Certain  general  clinical  characteristics  distinguish  the  secondary 
from  the  tertiary  syphilids. 
The  secondary  lesions  are : 

1.  Superficial,  benign,  resolutive. 

2.  Multiple,  profuse,  or  even  generalized. 

3.  Irregularly  disseminated,  but  usually  symmetrical. 

4.  Polymorphous. 
The  tertiary  lesions  are: 

1.  Deep,  destructive,  and  malignant. 

2.  Few  in  number,  often  single. 

3.  Distributed  in  circles  or  segments  of  circles,  and  usually  asym- 
metrical. 

4.  Usually  monomorphous. 

^Marked  only   with   the    slightest   irregularities    (like   cigarette   paper). 


GENERAL  CLINICAL  CHARACTERISTICS 


849 


Secondary  Syphilids 

The  becondarj  syphilids  affecting  the  general  integument  may  be 
discussed  under  the  following  heads : 
Macular  syphilids. 
Papular  syphilids. 
Syphilitic  alopecia. 


Fig.   193. — Macular  Syphilids.     (Fox.) 

Pustular  syphilids  (including  crusted  and  ulcerating  lesions). 

Squamous  syphilids. 

Pi<j,nientary  syphilids. 

Macular  Syphilid. — General  Macular  Syphilid. — This  eruption, 
often  called  the  syphilitic  roseola,  is  usually  the  first  secondary  erup- 
tion of  the  disease.     It  is  made  up  of  macules  of  various  sizes.     It  is 


850 


SYPHILIS  OF  THE  SKIN 


usually  most  marked  on  the  flanks ;  may  cover  the  whole  body ;  is  ex- 
tremely rare  on  the  face  and  hands.  If  untreated,  it  disappears  in  two 
to  six  weeks. 

Late,  Cikcinate,  Maculae  Syphilid. — Relapses  of  macular  syphi- 
lid assume  a  distinctly  circinate  form ;  it  is,  as  it  were,  the  shadow  of  a 
circinate  tuberculous  lesion. 

The  Papular  Syphilids — The  Papule. — The  syphilitic  papule  is 
very  slightlj^  elevated  above  the  surface  of  the  skin.    It  varies  from  the 


^fe- 
at 


Its 

first 


Fig.  194. — Papular  Syphilid;  Confluent  on  Face. 

size  of  the  head  of  a  pin  to  that  of  a  split  pea.  Its  summit  is  flat, 
though,  if  the  papule  be  very  small,  this  feature  may  be  lacking 
shape  is  absolutely  and  characteristically  circular;  its  color 
pink,  soon  takes  on  a  purplish,  ham,  or  copper  hue,  although  quite  fre- 
quently this  is  not  marked,  but  may  be  intensified  by  pressure.  Its 
surface  is  shining  and  tense,  and  this  may  be  covered  by  a  slight,  thin 
scale,  or,  more  commonly,  this  scale  is  promptly  shed,  leaving  a  faint, 


GENERAL  CLINICAL  CHARACTERISTICS 


851 


scaly  collar  around  its  base.  The  papule  is  hard,  and  has  in  some  meas- 
ure the  induration  characteristic  of  all  syphilitic  exudates.  From  the 
papule  all  the  other  elements  of  secondary  skin  syphilis  arise,  and  in 
the  earlier,  papular  eruptions,  it  is  not  uncommon  to  find  admixtures 
of  pustules,  squamous  papules,  etc. 

Papulae  Eruptions. — The  papular  syphilid  may  be  general  and 
disseminated  or  partial  and  scattered.  In  a  certain  proportion  of  cases 
the  general  macular  or  papu- 
lar eruption  is  preceded  by 
the  appearance  of  a  few  scat- 
tered papules.  As  a  rule, 
however,  the  first  papular 
eruption  is  generalized. 

Relapsing  papular  eriip- 
tions  tend  to  be  more  closely 
confined  to  certain  (inde- 
terminate) regions  the  later 
they  occur.  As  a  rule,  how- 
ever, the  papules  are  not 
grouped  in  any  geometric 
figTire ;  they  remain  dissemi- 
nated. Even  those  later 
papular  eruptions  are  often 
bilateral  and  symmetrical. 

Syphilitic  Alopecia.  — 
Alopecia  is  not  a  common 
feature  of  syphilis.  A  gen- 
eral falling  of  the  hair  may 
accompany  the  first  outbreak 
of  the  disease ;  but  this  is  no- 
ticeable only  to  the  patient  himself.  Much  more  characteristic  but 
quite  rare  is  the  "moth-eaten  poll"  illustrated  in  Fig.  195.  These  types 
of  alopecia   are  temporary.      Syphilis   does   not   cause  true  baldness. 

The  Pustular  and  Crusted  Syphilids. — The  pustular  syphilids  are 
all  (excepting  the  crusts  in  the  scalp]  rare  secondary  lesions.  Pustu- 
lation  is,  generally  speaking,  excited  by  dirt  and  debility.  It  is,  there- 
fore, properly  regarded  as  an  evil  omen. 

The  pustule  is,  as  it  were,  superadded  to  a  syphilitic  papule  and  sits 
upon  it,  destroying  but  little  tissue,  and  hence  leaving  little  or  no  scar. 
Pustular  lesions  may  be  scattered  among  the  papules  of  a  polymorphic 
eruption,  but  the  more  notable  pustular  eruptions  are  those  which  fol- 
low given  types  and  mimic  certain  nonsyphilitic  eruptions.  Accord- 
ingly we  distinguish : 

Herpetiform  syphilid. 


Fig.  195. — Syphilitic  Alopecia..     (Pusey.) 


852  SYPHILIS  OF  THE  SKIN 

Varicelloid  (or  varioloid)  syphilid. 
Acneifonn  syphilid. 
Impetiginous  syphilid. 
Ecthymatous  syphilid. 
The  titles  sufficiently  describe  them. 


Fig.  196. — Circinate  Papl  lu.suuamols  .Syphilid  on  Forearm.     (Fordyce.) 

The  Squamous  Syphilids — Gea^eealized  Squamous  Syphilid. — 
This  eruption  occurs  in  two  varieties — as  a  guttate  or  diffuse  psoriasis 
and  as  a  circinate  eruption.  The  character  of  the  eruption  is  the  same 
in  each.    They  may  be  seen  together  on  the  same  subject. 

Diagnosis. — When  not  associated  with  other  specific  lesions,  the 
squamous  syphilid  is  often  difficult  to  distinguish  from  psoriasis.    Much 


Fig.   197. — Squamous  Syphilid  of  Palm.     Note  circinate  border  and  absence  of  definite 

papules.     (Fordyce.) 


SECONDARY  SYPHILIS  OF  THE  MUCOUS  MEMBRANES       853 

light  is  thrown  upon  such  cases  by  study  of  the  previous  history.  Psori- 
asis tends  to  cluster  about  the  elbows  and  knees  and  upon  the  scalp,  and 
practically  never  affects  the  palms  and  soles;  its  scales  are  thick,  im- 
bricated, tightly  attached,  and  lying  in  several  layers,  so  that  it  is  diffi- 
cult to  scrape  them  all  away  and  get  down  to  the  livid  redness  of  the 
patch  beneath;  and  when  the  scales  all  rudely  rubbed  off  the  patch 
is  very  apt  to  bleed. 

Squamous  Plantar  and  Palmar  Syphilid. — If  the  eruption  is  seen 
when  it  first  comes  out,  its  papular  quality  may  be  readily  recognized 
in  the  manifest,  individual  papules  or  in  the  sinuous  line  of  confluent 
papules.  But  in  an  aged  lesion,  even  if  it  be  only  a  few  months  old, 
the  papules  may  almost  entirely  disappear,  and  all  that  is  left  visible  is 
the  squamous  almost  scarlike  change. 

In  this  condition  the  eruption  may  continue  active  and  spreading 
in  a  circinate  way  for  many  years,  during  which  time  an  occasional 
papule  may  become  visible,  or  the  confluent  red  ribbon  may  show  itself 
here  and  there.  But  the  general  characteristic  of  the  eruption  is  a 
purely  scaly  one.  The  scales  follow  one  of  two  types.  In  the  more 
common  form  they  produce  glistening  psoriatic  or  eczematous-looking 
spots.  Less  often  and  almost  exclusively  on  the  feet  they  heap  up  in  a 
great  callus. 

The  Pigmentary  Syphilid — This  extremely  rare  eruption  usually 
appears  as  a  reticular  brownish  patch  upon  the  neck.  It  is  extremely 
slow  to  disappear. 


SECONDARY  SYPHILIS  OF  THE  MUCOUS  MEMBRANES 

Distribution — They  may  affect  any  part  of  the  mucous  membranes 
and  also  any  part  of  the  skin  which  in  texture  and  moisture  simulates 
the  physical  conditions  of  mucous  membrane.  They  are  commonest 
in  the  mouth  and  throat  and  in  and  about  the  genitals. 

Etiology — Local  irritation  is  the  exciting  cause.  In  the  mouth  the 
local  irritation  of  tobacco,  whether  smoked  or  chewed,  stands  pre- 
eminent. About  the  folds  of  the  skin  uncleanliness  excites  them.  In 
the  male  they  are  more  common  in  the  mouth  than  elsewhere;  in  the 
female,  much  more  common  about  the  genitals  on  account  of  the  profuse 
secretions  there. 

Classification — -The  secondary  syphilids  of  the  mucous  membranes 
may  be  classified  as  follows : 

1.  Macular  syphilid. 

2.  Erosive  or  papulo-erosive  syphilid  (mucous  papule). 

3.  Ulcerative  syphilid. 

4.  Squamous  syphilid. 


854  SYPHILIS  OF  THE  SKIN 

5.  Smootli  atrophy  of  the  base  of  the  tongue. 

Of  these,  the  macular  syphilid  is  unimportant.  The  erosive  papular 
and  ulcerative  types  are  common  in  the  first  year  of  the  disease  and 
occur  infrequently  for  several  years  thereafter,  while  the  squamous 
types  are  rarely  seen  before  the  second  or  third  year,  and  may  continue 
indefinitely  thereafter. 

The  Erosive  ok  Papulae  Syphilid. — The  syphilitic  papule  upon 
a  moist  skin  or  mucous  membrane  surface  is  always  eroded.  Even 
upon  a  dry  surface  it  sheds  the  superficial  epithelium,  and,  when  kept 
moist,  the  deeper  layers  are  more  freely  exposed  and  exudation  from 
the  surface  of  the  papule  is  thus  a  constant  phenomenon  in  all  papular 
lesions  of  mucous  or  moist  surfaces. 

The  early  erosive  papular  lesion  may  be  so  slight  as  to  produce  no 
perceptible  irregTilarity  in  the  surface.  Its  top  is  level  with  the  sur- 
rounding mucous  membrane,  but  it  is  an  eroded  top,  and,  consequently, 
the  papule  appears  as  a  simple  erosion.  In  a  second  type  the  papule  is 
elevated  above  the  surface  to  a  slight  degree  and  becomes  a  typical, 
eroded  papule,  while  in  the  third  type  it  is  hypertrophic  and  becomes  a 
vegetating  papule  or  condyloma.  Hence  the  three  types  of  erosive  papu- 
lar syphilids : 

The  erosion. 

The  eroded  papule. 

The  vegetating  papule  or  condyloma. 

The  C ondyloma. — The  striking  characteristic  of  this  lesion  is  that, 
though  a  vegetating  one,  the  vegetation  is  relatively  low  compared  to 
the  extent  of  a  base ;  hence,  it  is  commonly  known  as  condyloma  latum. 
Its  foul  secretion,  its  irregular,  broken,  vegetating,  and  eroded  red 
surface  constitute  amplifications  of  the  characteristics  of  the  eroded 
papule. 

The  Ulcerative  Syphilid. — Just  as  the  papule  may  appear  as  a 
simple  erosion,  an  irritated  papule,  or  a  hypertrophied  papule,  so  the 
ulcer  may  appear  as  a  simple  ulcer,  as  an  ulcerated  papule,  or  as  an 
ulcerated  hypertrophied  papule. 

Leukoplakia. — By  leukoplakia  (tylosis,  milk  spot,  etc.)  is  meant 
a  chronic  inflammation  of  the  mucous  membrane  characterized  by  the 
appearance  of  pearly-white  or  bluish-white  patches.  These  patches  may 
appear  anywhere  inside  the  mouth,  but,  while  extremely  common  upon 
the  tongue,  they  are  very  rare  elsewhere.  I  have  record  of  only  seven 
cases  occurring  on  the  tongue  thickened  by  sclerotic  glossitis,  or  (rarely) 
destroyed  by  gumma. 

Prognosis. — Leukoplakia  is  one  of  the  most  inveterate  lesions  of 
syphilis.  Cases  lasting  four  or  five  years  are  not  uncommon,  and  one 
occasionally  sees  them  continue  for  ten  or  twenty. 

The  most  important  question  in  the  prognosis  of  leukoplakia  is  the 


SECONDARY  SYPHILIS  OF  THE  MUCOUS  MEMBRANES       855 

occurrence  of  epithelioma.  Most  authors  speak  of  it  as  common.  But 
among  my  cases  I  have  known  only  two  to  undergo  epitheliomatous 
change. 

Smooth  Atrophy  of  the  Base  of  the  Tongue. — This  lesion,  first 
classified  by  Virchow,  is  due  to  destruction  of  the  lymphoid  follicles  of 
the  base  of  the  tongue.  It  is  a  very  common  autopsy  finding  (Sym- 
mers  -^ )  and  can  be  identified  clinically  as  a  smoothness  of  that  part  of 
the  tongue  immediately  in  front  of  the  epiglottis. 

Diagnosis — I  know  no  pathogTiomonic  characteristic  to  distinguish 
the  ulcer  of  syphilis  from  that  of  mercury,  but  the  latter  rarely  occurs 
upon  the  fauces  or  upon  the  dorsum  of  the  tongue  or  in  the  angle  of 
the  lips,  where  syphilitic  ulcers  are  common ;  while  it  is  almost  typical 
of  mercurial  ulceration  to  find  a  lesion  on  the  cheek  or  gum  back  of  the 
last  molar  toothy  or  hetiveen  the  upper  or  lower  central  incisors. 

Vincent's  angina  may  be  mistaken  for  either  a  primary  or  a  sec- 
ondary syphilitic  mouth  lesion.     The  microscope  makes  the  diagTiosis. 

Treatment — Local  Treatment  of  Lesions  upon  the  Skin. — If 
the  lesion  is  upon  the  skin  it  is  usually  possible  to  keep  it  dry,  and  this 
drying  will  cure  erosion  or  vegetation  as  if  by  magic.  In  mild  cases  all 
that  is  necessary  is  to  cleanse  the  affected  region  thoroughly  twice  a  day 
with  warm  soap  and  water,  then  dry  and  apply  pure  calomel  or  calomel 
mixed  in  equal  parts  of  stearate  of  zinc  or  talcum. 

For  extensive  condylomata  it  may  be  necessary  to  paint  with  a  solu- 
tion of  permanganate  of  potash  (1:  1,000)  twice  a  day  and  to  inter- 
pose a  layer  of  absorbent  gauze  between  the  various  inflamed  surfaces 
after  powdering  the  whole  region  thickly,  until  salvarsan  effects  a  cure. 

Local  Treatment  of  Lesions  within  the  Mouth. — The  local 
treatment  is  mild  cauterization,  and  the  best  cauterizing  agent  is  the 
officinal  licjuor  hydrargyri  nitratis,  either  pure  or  diluted  to  one-half 
or  one-quarter  strength.  The  pure  fluid  can  be  applied  only  to  small 
lesions,  as  it  is  quite  painful.  This  application  should  he  made  not 
oftener  than  once  a  iveeh,  and  should  never  be  confided  to  the  hands  of 
the  patient,  since  overcauterization  makes  the  lesion  worse  instead  of 
better. 

In  order  to  prevent  relapses  of  secondary  syphilids  within  the  mouth, 
it  is  often  necessary  for  the  patient — 

To  stop  smoking  and  chewing  tobacco ; 

To  keep  the  teeth  and  gums  in  perfect  condition. 

''■Am.   Jour.   Med.    Sci.,   Dec,    1910. 


CHAPTER    LXXXVIII 

TERTIARY  SYPHILIDS  OF  THE  SKIN  AND  UPPER  RESPIRATORY 

TRACT 

The  syphilitic  tubercle  is  to  tertiary  skin  syphilis  what  the  papule 
is  to  secondary  skin  syphilis. 

The  pathological  difference  between  papule  and  tubercle  consists  in 
this :  The  papule  is  an  exudation  rather  upon  than  in  the  true  skin.  It 
does  not  destroy  any  of  the  tissue  of  the  skin,  therefore  it  does  not  leave 
a  scar.  The  tubercle,  on  the  other  hand,  is  an  exudation  within  the 
derma  which,  upon  healing,  leaves  a  permanent  scar. 

Tertiary  syphilids  of  the  skin  are  made  up  of  various  tubercular, 
tuberculopustular,  tuberculo-ulcerative  lesions,  and  of  gTimmatous  le- 
sions. "The  tubercle  may  be  described  as  a  gumma  of  the  skin,  and, 
conversely,  the  gumma  as  a  deep  tubercle  of  the  connective  tissue" 
(Morrow). 

Thus  tertiary  syphilids  may  be  divided  as  follows : 

Tubercular  lesions. 

Tuberculo-ulcerative  lesions,  and 

Subcutaneous,  gummata. 


TERTIARY  SYPHILIDS  OF  THE  SKIN 

THE    TUBERCTJLAE.    SYPHILID 

The  nonulcerative,  tubercular  syphilid  occurs  under  two  forms : 

The  disseminated  tubercular  syphilid,  and 

The  grouped  tubercular  syphilid. 

Either  of  these  may  be  scaly  upon  the  surface  (tuberculosquamous). 

The  tubercles  are  usually  small.  Their  favorite  positions  are  on  the 
forehead  (circle  of  Venus),  the  lips,  the  back,  the  leg,  the  outer  sur- 
face of  the  forearm,  and  the  back  of  the  shoulders.  A  single  tubercle 
may  constitute  the  whole  eruption,  or  there  may  be  great  numbers  of 
them. 

Grouped  Tubercular  Syphilid — The  favorite  locations  for  the 
grouped  lesions  are  those  just  mentioned. 

The  grouping  occurs  in  three  forms : 

1.  The  discrete  form. 

856 


THE  ULCERATIVE  TUBERCULAR  SYPHILID 


857 


2.  The  confluent,  circinate  form  (Fig.  198) o 

3.  The  massed  form. 

If  discrete,  the  tubercles  appear  to  be  ranged  in  circles  or  in  arcs 


Fig.  198. — Confluent  Tubercular  Syphilid  of  Nose.    (Fox.) 


of  circles,  forming  a  polycvclic  or  circular  design.  If  confluent,  they 
form  sinuous  scalloped  figures,  or  else  a  solid,  rounded,  indurated 
mass. 

THE  ULCERATIVE  TUBERCULAR  SYPHILID 

The  tertiary  ulcerative  skin  lesions  have  certain  characteristics  in 
common : 

1.  The  individual  tuhercles  are  cjuite  large. 

2.  They  may  become  serpiginous;  that  is  to  say,  the  ulcers  and 
tubercles  creep  over  the  surface.  The  advance  may  be  centrifugal  in  all 
directions  or  along  a  narrow  track  in  curves,  inclosing  portions  of 
healthy  skin ;  or  the  advance  takes  place  in  only  one  direction,  v^hile  the 
opposite  edge  of  the  ulcer  is  cicatrizing. 


858 


TERTIARY  SYPHILIDS  OF  THE  SKIN 


Thus  the  serpiginous  ulcer  is  usually  a  flat  plane  of  scar  tissiio  more 
or  less  completely  surrounded  by  a  ditch  of  ulceration  set  in  an  in- 
durated syphilid  as  a  base. 


Fig.  199. — Serpiginoxts  TuBEBCULO-trLCEEATivE  Syphilid.     (Fox.) 


3.  They  may  he  phagedenic.  Phagedena  is  malignant,  rapidly 
spreading  gangrene. 

It  may  spread  chiefly  over  the  surface  (superficial  phagedena)  ; 
or  may  eat  its  way  deeply  into  the  underlying  tissues  (deep  phag- 
edena). 

The  course  of  phagedena  is  most  capricious.  Even  when  untreated 
its  rapid  spread  will  suddenly  stop  and  the  slough  will  be  cast  off 


THE  ULCERATIVE  TUBERCULAR  SYPHILID 


859 


and  the  lesion  go  on  to  heal;  or,  having  stopped,  it  may  take  a  new 
start. 

Characteristics  of  the  Lesion — The  ulcerative  tubercular  syphilid 
may  appear  clinically  as  a  pustular,  a  crusted,  or  an  ulcerating  lesion. 
Pustules  are  infrequent  and  rapidly  break  to  take  on  one  of  the  other 
types.    Whether  the  lesion  is  crusted  or  ulcerated  depends  largely  upon 


Fig.  200. — Gummatous  Ulcer;  Tibial  Node.     (Fordyce.) 


the  accident  of  its  situation.  Usually  it  will  be  found  covered  with  a 
typical  syphilitic  scab ;  but  if  it  has  recently  been  picked  or  if  it  lies 
in  some  place  subjected  to  constant  friction,  the  scab  may  be  off  and 
a  typical  syphilitic  ulcer  disclosed. 

Thus  the  lesion  may  appear  in  one  of  the  following  forms  (we  give 
only  the  most  important  ones,  since  they  are  useful  merely  for  clinical 
identification)  : 

Tertiary  ecthyma. 


860     TERTIARY  LESIONS  OF  THE  UPPER  RESPIRATORY  TRACT 

Rupia. 

Other  forms  of  crusted  syphilids. 

The  ulcerated  syphilid. 


SUBCUTANEOUS  GUMMA 

The  gumma  begins  as  an  insensitive,  little,  hard  subcutaneous  lump, 
freely  movable  over  the  subjacent  tissues,  the  integument  slightly  mov- 
able over  it.  In  this  condition  it  may  remain  stationary  for  months, 
but,  as  a  rule,  it  grows  slowly  in  size,  and  within  a  few  weeks  has  infil- 
trated the  skin. 

The  skin  becomes  red  and  tense,  then,  as  the  gumma  begins  to  soften 
centrally,  purple,  boggy,  and  tender  to  pressure.  Actual  fluctuation 
may  be  determined  and  may  cover  quite  a  large  area.  As  the  tenderness 
continues,  and  may  even  be  accompanied  by  intense  pain,  incision  is 
often  practiced  to  relieve  these  symptoms.  The  result  is  startling.  In- 
stead of  a  gush  of  pus  there  oozes  forth  only  a  few  drops  of  bloody  or 
purulent  serum ;  the  fluctuation  persists ;  the  sj'mptoms  are  unabated ; 
the  incision  has  merely  produced  a  gTimmatous  ulcer. 

The  gummatous  ulcer  resembles  the  ulcerated  tubercle,  but  it  is 
deeper  and  its  base  is  more  sloughy. 

Diagnosis. — Gumma  may  be  mistaken  for  varicose  ulcer  of  the  leg. 

SYPHILITIC    LEG   ULCER  VARICOSE  LEG  ULCER 

1.  Situation.  —  Anywhere.     Often     in      1.  Only  in  lower  third  of  leg.    Habitu- 

calf  or  in  upper  half  of  leg.  ally  on  internal  surface. 

2.  Number. — Often  multiple.  2.  Rarely  multiple. 

3.  Shape. — Round  or  polyeyclie.  3.  Irregular. 

4.  Edges. — Sharp,   deep,    or  e-'^en   un-  4.  Rounded,     shallow,     never     under- 

dermined.  mined. 

5.  Surrounding    Tissues. — Very    slight      5.  Extensively     and    irregularly    pig- 

areola,  unless  there  be  old  scars  mented,  thickened  and  adherent. 

or  other  foci  of  syphilitic  infil- 
tration. 

Besides  this,  there  is  on  the  one  hand  a  history  of  syphilis,  on  the 
other  varicose  veins. 


TERTIARY  LESIONS  OF  THE  UPPER  RESPIRATORY  TRACT 

DIFFUSE  SCLEROTIC  GLOSSITIS 

The  lesion  is  a  diffuse  sclerosis  in  the  muscle  of  the  tongue.  It  is 
quite  rare  and  is  always  accompanied  by  superficial  glossitis,  either 
simple  depapillation  or  leukoplakia. 


ULCERATION  OF  THE  PALATE  AND  VELUM  861 


GUMMA  OF  THE  TONGUE 

Gumma  of  the  tongiie  is  relatively  rare.     One-third  of  the  cases  are 
associated  with  sclerosis  of  the  tongue. 

EPITHELIOMA  GUMMA 

1.  Occurrence. — ^Almost  exclusively  in  1.  Any   age;   either  sex.     Histoi-y  of 

men  over  forty-five  years  of  age.  previous  syphilis. 

2.  Situation. — Usually    on    edge;    may  2.  Usually  on  dorsum.     Never  on  un- 

be  on  under  surface.  der  surface. 

3.  Number. — Single.  3.  May  be  multiple. 

4.  Leukoplakia. — May  precede.  4.  May  accompany. 

5.  Characteristics. — A     shallow,     fun-  5.  A  deep  sloughing  ulcer,  with  sharp, 

gating  ulcer,  with  thick,  everted  undermined  edges,  upon  a  mod- 
edges,  upon  a  base  of  wooden  erately  indurated  base.  It  does 
hardness.  It  bleeds  very  readily;  not  bleed  readily;  its  discharge 
its  discharge  is  foul.  is  not  very  foul. 

6.  Pain. — Severe  and  lancinating.  6.  Slight  or  absent. 

7.  Lymph  Nodes. — Soon  and  progres-  7.  Enlargement  slight  or  absent. 

sively  enlarged. 

8.  Biopsy. — Epithelial  pearls.  8.  Gumma. 

9.  Treatment. — No  medicines  have  the  9.  Salvarsan. 

least  effect. 


ULCERATION  OF  THE  PALATE  AND  VELUM 

The  typical  and  terrible  lesion  of  syphilis  is  the  phagedenic  gum- 
matous ulcer. 

This  begins  as  a  ditfuse  infiltration,  producing  redness,  tumefaction, 
and  relative  immobility  of  the  velum.  But  it  causes  scarcely  any  pain, 
and  the  patient  usually  pays  no  attention  to  it  until,  suddenly,  ulcera- 
tion and  phagedena  set  in. 

The  onset  of  phagedena  is  exceedingly  rapid.  The  patient  goes  to 
bed  at  night  thinking  himself  well,  and  awakes  with  a  hole  in  his  pal- 
ate, or  with  gTeat  patches  of  necrosis  replacing  what  the  day  before 
was  a  comparatively  innocent,  painless  infiltration.  Even  now  the  pain 
is  not  great,  and  the  discomfort  is  inconsiderable.  But  the  foul  odor 
from  the  sloughing  tissue,  or  the  sense  of  a  hole  in  the  velum,  soon 
brings  the  patient  to  his  physician. 

Examination  then  reveals  either  an  area  of  dark  greenish  slough  in 
the  palate,  or  else  a  perforation  surrounded  by  a  slough.  If  the  perfora- 
tion is  of  any  size  the  voice  assumes  a  nasal  quality  and  the  breathing 
may  be  accompanied  by  a  rattling  gurgle,  due  to  the  flapping  to  and  fro 
of  partially  detached  bits  of  the  palate.  When  the  patient  tries  to  swal 
low  he  has  great  difficulty  in  preventing  fluids  from  regurgitating 
through  the  perforation  into  his  nose. 


862     TERTIARY  LESIONS  OF  THE  UPPER  RESPIRATORY  TRACT 

GUMMA  OF  THE  NASAL  SEPTUM 

Gumma  of  the  nasal  bones  is  always  insidious  and  rapidly  destruc- 
tive in  its  onset,  like  that  of  the  palate  and  the  velum. 

The  septum  is  the  part  usually  involved. 

The  first  symptom  noticed  hy  the  patient  is  an  increase  in  the  dis- 
charges from  his  nose  and  the  presence  of  hlood  in  these  discharges.  He 
vv^ill  also  confess  that  the  sense  of  smell  is  either  blunted  or  com- 
pletely lost. 

Examination  (anterior  rhinoscopy)  reveals  a  perforation  in  the  sep- 
tum, which  is  usually  situated  at  least  an  inch  from  the  anterior  nares, 
though  it  may  appear  at  the  junction  of  bone  and  cartilage.  This  per- 
foration is  either  surrounded  by  a  sloughing  sore  or  else  plugged  with 
scabs  and  dead  bone. 

Severe  or  neglected  cases  go  on  to  total  destruction  of  the  nasal  sep- 
tum, and  may  be  identified  the  moment  they  enter  one's  office  by  the 
peculiar  snufiling,  purring  sound,  due  to  the  flapping  of  necrotic  tissue 
excited  by  the  breathing. 

With  the  healing  of  such  a  lesion  the  bridge  of  the  nose  sinks  in,  and 
may  even  fall  flat  to  the  level  of  the  patient's  face  if  all  the  bones  have 
been  destroyed. 

TERTIARY  SYPHILIS  OF  THE  LARYNX 

The  tertiary  lesions  of  laryngeal  syphilis  are: 

Ulceration. 

Gumma. 

Fibroid  degeneration. 

Perichondritis. 

Paralysis. 

The  common  symptom  is  painless  chronic  aphonia,  the  vox  rauca 
syphilitica. 

SYPHILIS  OF  THE  INTERNAL  EAR 

The  symptom  of  syphilis  of  the  internal  ear  is  nerve  deafness ; 
coming  on  suddenly  and  rapidly  becoming  complete.  It  may  occur  at 
any  time  after  the  appearance  of  secondary  lesion  and  is  one  of  the 
commonest  forms  of  relapse  of  syphilis  in  the  nervous  system  after  the 
administration  of  salvarsan.  The  lesion  is  either  in  the  labyrinth  or  in 
the  nerve  itself.  Even  though  resulting  from  the  administration  of 
salvarsan,  like  other  evidences  of  relapse  thereafter,  it  may  be  best  cured 
by  the  administration  of  the  same  drug  (Ellis  and  Swift). ^ 

^Jour.  A.  M.  A.,  1915,  Ixiv,  1471. 


CHAPTEK   LXXXIX 

SYPHILIS  OF  THE  NERVOUS  SYSTEM,  THE  EYE,  THE  BONES,  THE 
VISCERA,  AND   OTHER  REGIONS 

SYPHILIS  OF  THE  NERVOUS  SYSTEM 

Geottping  the  lesions  of  syphilis  according  to  the  tissues  involved, 
one  may  affirm  that  syphilis  of  the  skin  is  the  most  frequent,  syphilis  of 
the  mucous  membranes  the  most  infectious,  syphilis  of  the  nervous  sys- 
tem the  most  malignant  manifestation  of  the  disease.  Syphilis  of  the 
nervous  system  is  indeed  malignant  in  that  it  occurs  in  a  large  propor- 
tion of  syphilitics  and  that  its  lesions  are  always  grave  and  often 
incurable. 

Thus,  among  my  2,500  cases,  504  (20  per  cent)  were  afflicted  with 
syphilis  of  the  nervous  system,  and  of  all  late  lesions,  42  per  cent  were 
in  the  nervous  system. 

Etiology. — There  is  good  reason  to  believe  that  every  lesion  of 
syphilis  in  the  human  body  results  from  an  infection  occurring  at  the 
time  which  may  be  loosely  described  as  that  of  the  outbreak  of  secondary 
symptoms.  Examination  of  the  spinal  fluid  shows  some  evidence  of 
syphilitic  invasion  of  the  central  nervous  system  in  from  60  to  TO  per 
cent  of  cases  at  this  period  (Wile  and  Stokes).^  Indeed  in  perhaps 
10  to  15  per  cent  of  cases  the  invasion  of  the  nervous  system  can  be 
demonstrated  even  before  the  skin  lesions  of  secondary  syphilis  appear. 

This  early  infection  of  the  nervous  system  may  pennanently  sub- 
side, or  may,  within  the  first  few  years  of  the  disease,  give  rise  to. 
characteristic  syphilitic  infiltration  of  the  meninges,  or  of  the  arteries, 
that  result  in  the  so-called  cerebrospinal  syphilis.  Although  tabes  and 
paresis  have  been  shown  to  be  definitely  the  effect  of  syphilis,  inasmuch 
as  the  infected  tissue  contains  spirochetes,  yet  these  two  conditions  are 
peculiar  both  in  their  pathologic  characteristics  and  in  the  fact  that 
they  do  not  develop  until  at  least  three  or  four  years,  and  usually 
from  8  to  15  years,  after  the  infection  of  the  individual.  This  is  doubt- 
less due  to  sensitization  of  the  nervous  tissue  by  an  early  infection  on 
account  of  which  it  reacts  later  in  the  form  of  tabes  and  paresis  (cf. 
Collins  ^  and  Fordyce  ^). 

VoMr.  A.  M.  A.,  1915,  Ixiv,  979. 

UUd.,  Ixv,  139. 

"  Am.  Jour.  Med.  Sciences,  1915,  cxlix,  781. 

863 


864  SYPHILIS  OF  THE  NERVOUS  SYSTEM 

ISTageotte  observed  in  1894  that  a  slight  meningitis  about  the  pos- 
terior nerve  roots  affecting  these  and  ascending  with  them  to  the  cord 
was  apparently  the  earliest  lesion  of  tabes.  This  view,  though  disputed 
at  first,  has  gradually  been  accepted  and  the  same  interpretation  has 
been  placed  upon  paresis.  Both  of  these  so-called  parasyphilids  are, 
therefore,  now  believed  to  be  due  to  an  early  meningitis,  a  sensitization 
of  the  tissue  of  the  nervous  system  and  the  subsequent  syphilitic  out- 
breaks therein  in  later  years  causing  a  combined  meningitis  and  en- 
cephalitis or  atrophy  of  the  lateral  columns  of  the.  cord. 

Occurrence. — Collins  has  classified  100  cases  of  syphilis  of  the 
nervous  system  of  which  the  earliest  appeared  one  month  after  the  onset 
of  chancre,  the  latest  30  years  thereafter.  In  6  the  symptoms  began 
within  a  year.  The  greater  number  developed  in  from  3  to  7  years. 
A  clear  history  of  secondary  lesions  was  obtained  in  only  29  cases,  and 
only  37  cases  received  the  full  routine  early  treatment  (mostly  of  the 
presalvarsan  period).  These  figures  present  the  clinical  facts  quite 
graphically.  Probably  a  larger  proportion  of  cases  than  appear  in 
these  statistics  have  definite  headaches  during  the  first  six  months  of 
the  disease.  But  these  usually  subside  spontaneously  and  the  case  that 
is  to  suffer  subsequently  from  grave  lesions  in  the  nervous  system  is 
one  which  has  usually  had  but  few  early  symptoms  and  but  little  or  no 
treatment  therefor. 

Pathology — The  predominating  lesions  are  meningeal  infiltration 
which  is  seen  most  commonly  and  characteristically  about  the  base  of 
the  brain,  and  arterial  syphilitic  disease  that  results  in  gumma,  throm- 
bosis, or  rupture  of  the  vessel,  and  the  sclerotic  processes  of  tabes  and 
paresis. 

The  changes  in  the  cerebrospinal  fluid  have  already  been  alluded  to 
(p.  809). 

Symptoms. — Collins  ^  classifies  the  symptoms  of  brain  syphilis  as 
follows : 

1.  Headache. — Headache  is  the  constant  symptom  of  all  syphilitic 
lesions  of  the  brain.  If  severe  it  is  usually  characteristically  nocturnal 
in  type,  being  greatly  relieved  by  day  and  may  be  of  the  greatest  in- 
tensity. But  in  connection  with  the  graver  and  later  lesions  the  head- 
ache may  be  both  mild  and  inconstant. 

2.  Alteration  of  Personality. — This  is  often  slight  showing 
itself  only  in  inaccuracy  or  inattentiveness  of  mind,  often  interpreted 
as  neurasthenia,  and  in  the  graver  conditions  passing  to  complete 
insanity. 

3.  Paralysis  of  the  Cranial  Nerves. — Affections  of  the  motor 
oculi  are  the  most  frequent,  causing  diplopia  and  ptosis.  Any  or  all 
of  the  cranial  nerves  may,  however^  be  involved  in  the  basal  meningitis, 

^N.  Y.  Med.  Jour.,  Feb.  26.  1916. 


SYPHILIS  OF  THE  NERVOUS  SYSTEM  865 

deafness  and  blindness  being  not  unusual  results,  while  arterial  lesions 
of  the  hemispheres  may  lead  to  hemiplegia. 

Pupillary  irregularity  and  fixity  and  the  so-called  Argyll-Robertson 
pupil  are  as  rare  with  the  early  as  they  are  common  with  the  later 
lesions  of  syphilis  of  the  nervous  system. 

4,  Insomnia. 

5o  DisoKDER  OF  MoTOK  FUNCTION. — Shivering  attacks,  stiffness, 
convulsions,  paralyses,  pain,  aphasia,  etc. 

Symptoms  of  Spinal  Cord  Lesions — The  most  striking  symptoms  are 
paralysis,  partial  and  complete,  of  bladder  and  bowel,  ataxia  or  mus- 
cular incoordination,  paresthesia,  derangement  (e.  g.,  Argyll-Robert- 
son pupil,  Babinski's  sign)  and  abolition  of  reflexes,  and  pain.  Even 
the  briefest  clinical  study  of  these  various  manifestations  require  far 
more  space  than  we  have  to  devote  to  them.  They  are  not  mutually 
exclusive,  nor  is  it  possible  alwaj^s  to  predicate  with  absolute  accuracy 
a  given  lesion  to  a  given  set  of  symptoms;  for  the  lesions  are  usually 
irregular  and  acute,  the  symptoms  complex  and  confusing. 

Diagnosis. — Among  the  more  striking  features  in  the  clinical  diag- 
nosis of  syphilis  of  the  nervous  system,  we  may  mention  the  following : 

1.  Apoplexy  or  hemiplegia  occurring  before  the  age  of  forty-five 
is  usually  syphilitic. 

2.  Ocular  paralysis  and  nerve  deafness  arB  usually  syphilitic. 

3.  Fixity  and  irregularity  of  the  pupil  with  tremor  of  the  tongue 
is  a  suggestion  of  paresis. 

4.  The  lesions  of  tabes  may  exist  for  many  years  without  showing 
any  striking  reflex  changes  excepting  abolition  of  the  ankle  jerk. 

5o  Spastic  spinal  syphilis  gives  a  clinical  picture  grossly  simulating 
tabes,  but  with  exaggeration  instead  of  diminution  of  reflexes. 

6.  The  differential  diagTiosis  of  these  various  lesions  is  made  upon 
the  clinical  sjanptoms  supported  by  the  investigation  of  the  spinal  fluid 
(p.  809). 

Prognosis. — If  taken  in  time,  syphilis  of  the  nervous  system,  how- 
ever grave,  however  fulminating,  may  often  be  controlled  and  actually 
cured,  so  that  no  trace  of  it  remains.  The  wildest  mania,  the  deepest 
coma,  the  most  complete  paralysis,  may  yield  like  magic  to  prompt  and 
efficient  treatment.  Medicine  can  boast  no  miracle  gTeater  than  the 
effect  of  specific  treatment  upon  syphilis  of  the  nervous  system. 

But  such  wonders  cannot  always  be  accomplished  even  by  prompt 
and  efficient  treatment.  In  any  case,  if  treatment  is  delayed  until  the 
nerves  have  degenerated  and  muscles  atrophied,  it  is  vain  to  ask  of  any 
treatment  the  real  miracle  that  would  be  required  to  restore  the  patient 
to  perfect  health. 


866  SYPHILIS  OF  BONE 

SYPHILIS  OF  THE  EYE 

Iritis. — It  occurs  usually  between  the  fourth  and  the  twelfth  month 
of  the  disease.  Half  the  cases  of  iritis  seen  by  the  ophthalmologist  are 
said  to  be  syphilitic. 

Diagnosis. — Is  the  iritis  hut  one  of  a  number  of  ocular  lesions? 
This  question  always  merits  an  accurate  answer;  for,  while  no  lesion 
is  more  benign  than  the  mild  iritis  of  early  syphilis,  no  lesion  is  more 
fatally  misleading  than  that  same  iritis  when  it  conceals  the  onset  of 
chorioretinitis. 

Hence  every  syphilitic  iritis  demands  a  thorough  ophthalmoscopic 
examination. 

Chorioretinitis  and  Retinitis. — Syphilis  is  the  most  frequent  cause 
of  chorioretinitis,  one  of  the  rare  causes  of  retinitis. 

Optic  Neuritis.^The  optic  nerve  is  said  to  contribute  25  per  cent 
of  ocular  syphilis.    It  is  one  of  the  common  nerve  lesions. 

Interstitial  Keratitis — This  is  common  in  hereditary  syphilis,  ex- 
tremely rare  in  acquired  syphilis.  Many  authorities  maintain  that  all 
interstitial  keratitis  is  syphilitic. 


SYPHILIS  OF  BONE 

Bone  syphilis  resembles  brain  syphilis  in  this :  it  may  manifest  itself 
first  by  pain,  worse  at  night  (osteocopic  pains,  headache),  at  the  time 
of  the  first  general  outbreak  of  symptoms,  and  the  lesion  may  follow 
one  of  three  courses,  viz. : 

1.  The  pain  having  been  relieved  by  time  or  treatment,  no  further 
bone  (or  brain)  lesions  may  appear,  or 

2.  The  pain  may  be  followed  (with  or  without  an  interval  of  re- 
mission) by  grave  bone  (or  brain)  lesions,  or 

3.  The  grave  lesions  may  attack  a  bone  (or  brain)  in  which  no  pain 
was  felt  at  the  onset  of  secondary  symptoms. 

Pathology — There  may  be  osteoperiostitis,  gummatous  periostitis, 
or  osteomyelitis. 

Syphilitic  osteoperiostitis  (the  usual  lesion)  is  an  exudative  thick- 
ening of  the  periosteum,  which  results  in  productive  osteitis  and  the 
formation  of  bony  exostosis  unless  promptly  checked  by  treatment.  The 
tibia  is  the  bone  most  often  involved. 

Symptoms — Osteopekiostitis,— The  lesion,  as  a  rule,  develops 
very  slowly.  When  once  established,  this  shows  itself  as  a  thickening  of 
the  bone.  It  is  usually  sitiuited  near  the  extremity  of  a  long  bone  (tibia. 
clavicle,  ulna),  and  is  diffuse,  irregular,  insensitive,  and  without  sub- 


SYPHILIS  OF  BONE 


867 


jective  symptoms.  Such  a  deformity  simulates  nothing  else  than  an 
exuberant  callus,  following  fracture,  from  which  it  may  be  readily  dis- 
tinguished by  the  history.  The  patient  usually  attributes  the  pain  af 
the  onset  to  some  imaginary  injury. 

Gumma. — This  lesion  usually  follows  an  acute  course  in  marked 


Fig.  201. — Saber  Tibia  of  Hereditary  Syphilis.  Diffuse  osteosclerosis  of  shaft  of  tibia 
projecting  outward  and  also  encroaching  upon  the  medullary  canal.  (Case  of  Dr  Jaeger. 
Skiagraph  by  Dr.  Cole.) 


contrast  to  the  chronicity  of  productive  osteoperiostitis.     The  onset  is 
usually  sharp  with  pain  and  tenderness. 

Swelling. — The  swelling  which  may  be  obscured  by  the  deep  situa- 
tion of  the  bone  (spine,  femur),  is  at  first  a  flattened,  hard,  circum- 
scribed, tender  swelling  attached  to  the  bone.  As  it  grows,,  it  becomes 
softer;  the  tissues  over  it  first  adhere,  then  become  edematous,  and 


868  SYPHILIS  OF  BONE 

finally  involved  in  the  gumma.  In  its  subcutaneous  situations  (tibia, 
cranial  bones)  periosteal  gumma  passes  tliroTigli  precisely  tbe  same 
clinical  phases  as  does  subcutaneous  gumma,  except  that  it  is  from 
the  beginning  adherent  to  and  in  some  measure  incorporated  in  the 
bone. 

Diao'nosiCo — The  x-ray  discloses  a  typical  wavy  irregularity  and 


Fig.  202. — Gumma  of  Inner  Condyle  of  Femur  and  Outer  Condyle  of  Tibia  (Heredi- 
tary Syphilis)  ;  Arthritis.  (Compare  normal  joint.)  (Case  of  Dr.  Jaeger.  Skiagraph 
by  Dr.  Cole.) 


thickening  of  the  periosteum,  even  at  a  distance  from  the  clinical  lesion, 
and  often  also  in  bones  that  are  not  recognizably  diseased  (Fig.  201). 

Gumma  shows  as  an  erosion  (Fig.  202)  and  is  always  accompanied 
by  periostitis. 

A  fracture,  with  bone  ends  in  apposition,  that  does  not  unite  is 
usually  syphilitic,  even  though  history,  physical  examination  and  x-ray 
reveal  nothing. 


SYPHILIS  OF  TRACHEA,  BRONCHI,  AND  LUNGS  869 


SYPHILIS  OF  THE  ARTICULATIONS 

Syphilis  simulates  every  joint  disease  from  rheumatism  to  tuber- 
culosis.   Its  lesions  may  be  classified  under  the  following  types : 

Arthralgia. 

Hydrarthrosis. 

Pseudorheumatism  (extremely  rare). 

Tertiary  arthritis  and  osteo-arthritis  (gTimniatous). 

Deforming  arthritis. 

Syphilitic  Arthralgia — The  special  characteristics  of  syphilitic 
arthralgia  are : 

1.  There  is  no  discoverable  lesion  sufficient  to  account  for  the  pain. 

2.  ISTocturnal  exacerbation  and  relief  by  exercise. 

3.  Frequent  in  larger  joints  (shoulder,  knee,  elbow),  rare  in  smaller 
ones ;  if  polyarticular,  one  joint  is  usually  much  more  painful  than  any 
other. 

Diagnosis. — The  x-ray  shows  syphilitic  periostitis. 


SYPHILIS  OF  THE  MUSCLES 

Apart  from  the  muscle  pains  that  may  occur  in  early  syphilis, 
syphilis  of  muscles  is  extremely  rare.  I  have  record  of  only  two 
cases,  one  of  torticollis  (sternomastoid  spasm),  one  of  bicipital  con- 
tracture. 

The  lesions  described  are :  Contracture,  interstitial  myositis,  gum- 
matous myositis,  myositis  ossificans. 

Tendons  and  aponeuroses  are  scarcely  ever  involved  except  by  ex- 
tension of  a  syphiloma  from  the  surrounding  parts.  The  occipitofrontal 
aponeurosis  is  said  sometimes  to  be  inflamed  in  early  syphilis.  I  have 
record  of  one  case  of  gumma  of  the  tendo  Achillis  in  a  patient  with 
many  other  tertiary  lesions. 

Acute  bursitis  or  chronic  bursitis  with  effusion  may  complicate 
arthritis.     It  is  extremely  rare. 

Gummatous  bursitis  is  far  more  common.  It  occurs  almost  always 
in  the  prepatellar  bursa. 


SYPHILIS  OF  TRACHEA,  BRONCHI,  AND  LUNGS 

Syphilis  of  the  trachea  and  bronchi  is  associated  clinically,  on  the 
one  hand,  with  laryngeal  syphilis,  on  the  other  with  lung  syphilis ;  but 
bronchial  or  peribronchial  syphilitic  lesions  are  entirely  distinct  from 


870  SYPHILIS  OF  THE  LIVER 

those  beginning  in  the  lung  tissue.  These  lesions  are  extremely  rare. 
They  are  diffuse  infiltrations  in  and  about  the  trachea  with  surface 
ulceration  irregular  in  extent  and  depth. 

Syphilitic  Pneumonia. — The  interstitial  pneumonia  caused  by  syph- 
ilis is  seen  as  an  uncomplicated  process  almost  exclusively  in  cases  of 
hereditary  syphilis.    This  is  the  ivliUe  pneumonia  of  the  new-horn. 

Cicatricial  Lesions — Syphilitic  sclerosis  of  the  lung  is  the  com- 
mon pulmonary  lesion  of  acquired  syphilis.  It  is  usually  irregular  in 
distribution,  and  is  believed  to  be  more  common  in  the  lower  th£  i  in  the 
upper  lobe,  in  the  right  than  in  the  left  lung  (cf.  Stanley  ■^). 

Bronchiectasis — Associated  with  the  interstitial  syphilitic  changes 
in  the  adult  lung  one  almost  always  finds  bronchial  dilatation  of  various 
shapes  and  sizes.  In  many  instances  the  bronchiectasis  is  so  marked 
as  to  be  the  chief  lesion  and  produces  cavities  of  considerable  size,  the 
presence  of  which  can  be  determined  during  life. 

Hereditary  Pulmonary  Syphilis — Usually  there  are  no  symptoms. 
The  patient  is  either  still-born  or  dies  within  a  few  hours,  and  a  white 
pneumonia  is  discovered  among  other  visceral  lesions  after  death. 

In  the  Adult. — The  following  types  are  recognized : 

1.  The  silent  type. 

2.  The  bronchopneumonic  type. 

3.  The  tracheal  type. 

4.  The  pseudotubercular  type. 

The  diagnosis  is  suggested  by  associated  lesions  in  the  other  viscera, 
by  the  Wassermann  reaction,  by  the  absence  of  tubercle  bacilli  from  the 
sputum,  by  the  x-ray,  and  by  the  effect  of  salvarsan. 


SYPHILIS  OF  THE  LIVER 

Jaundice  is  a  frequent  symptom  in  grave  hereditary  syphilis :  post 
mortem  the  liver  is  found  packed  with  spirochetes.  A  similar  jaundice, 
but  mild  and  transient,  occurs  in  the  early  months  of  acquired  syph- 
ilis— ^usually  before  the  skin  lesions  appear. 

But  the  term  "liver  syphilis"  is  broadly  applied,  not  to  this  tran- 
sient lesion,  but  to  the  sclerogummatous  lesion,  which  is  one  of  the 
commonest  and  most  obvious  visceral  manifestations  of  syphilis.^ 

Occurrence.- — Tertiary  syphilis  of  the  liver  occurs  in  the  later  years 
of  the  disease.  It  is  often  not  diagnosed  during  life ;  hence  one  cannot 
keep  an  accurate  clinical  record  of  its  frequency.  Alcohol,  hardship, 
and  neglect  are  obvious  etiological  factors. 

Pathology. — The  liver  is  usually  large  and  deformed.     It  may  or 

^Brit.    Med.   Jour.,    Oct.    7,    1911. 

*Cf.  Schrayer,  Jmr.  A.  M.  A.,  1912,  Iviii,  681. 


SYPHILIS  OF  THE  TESTICLE  871 

may  not  be  adherent  to  the  surrounding  organs ;  but  the  capsule  almost 
always  shows  more  or  less  irregular  whitish  thickening.  This  thicken- 
ing may  be  due  to  a  diffuse  productive  perihepatitis  or  to  the  thick  scars 
left  by  healed  gaimmata. 

The  irregular  shape  of  the  liver  is  due  to  bands  of  dense  sclerotic 
tissue  traversing  it  irregularly,  crisscrossing  at  various  points. 

The  gummata  are  found  either  as  hard,  ^''ellowish  nodules  or  as 
cheesy  masses  at  the  intersection  of  several  bands  of  sclerosis  or  beneath 
(and  involving)  the  capsule.  These  giimmata  are  rarely  smaller  than 
a  pea,  and  may  attain  an  enormous  size,  projecting  noticeably  from  the 
surface  of  the  enlarged  viscus.     They  are  usually  quite  numerous. 

Symptoms. — The  symptoms  of  hepatic  syphilis — when  it  excites 
symptoms — are  usually  comparable  to  those  of  (nonsyphilitic)  cirrhosis 
or  of  neoplasm.  There  may,  however,  be  no  local  signs  of  disease,  in 
which  case  there  may  be  fever  or  a  marked  and  progressive  cachexia. 

We  may,  therefore,  classify  the  types  of  hepatic  syphilis  according 
to  the  nonsyphilitic  lesions  which  they  simulate,  arranged  in  what  is 
probably  their  order  of  frequency: 

1.  Neoplastic  type. 

2.  Cirrhotic  type. 

3.  Cachectic  type. 

4.  Febrile  type. 

5.  Silent  type. 


SYPHILIS  OF  THE  STOMACH  AND  INTESTINES 

Sclerogummatous  syphilitic  infiltration  of  the  lower  six  inches  of 
the  rectum  is  a  recognized  cause  of  stricture  in  that  part  of  the  gut.  It 
is  usually  a  pathologic  post  mortem  finding.  Eare  instances  of  syphilis 
have  also  been  recorded  in  other  parts  of  the  intestines  as  they  have  in 
the  pancreas  and  spleen,  etc. 

Syphilis  perhaps  causes  a  minority  of  the  ulcers  of  the  stomach, 
but  the  pathologic  diagnosis  is  almost  as  confusing  as  the  clinical  diag- 
nosis is  vague.^ 


SYPHILIS  OF  THE  TESTICLE 

(See  page  592.) 

*Cf.  Downes  and  Le  Wald,  Jour.  A.  M.  A.,  1915,  Ixiv,  1824;  Brusch  and 
Sclineider,  Bcrl.  klin.  Wochenschr.,  1915,  lii,  2?,;  Curtis,  Jour.  A.  M.- A.,  1909,  hi, 
1159;  Eudnitski,  Arch.  f.  Verdauungskrank.,  1909,  xv,  1. 


872  SYPHILIS  OF  THE  HEART  AND  ARTERIES 

SYPHILIS  OF  THE  HEART  AND  ARTERIES 

All  syphilis  is  vascular  syphilis;  but  certain  of  the  late  lesions  of 
syphilis,  especially  affecting  the  vascular  system,  are  v^orthy  of  note. 

Syphilis  of  the  Heart. — Gumma  of  the  heart  is  rare,  usually  occurs 
in  the  silent  portions  of  the  organ,  is  not  diagnosed  during  life,  and  is 
said  to  be  the  cause  of  one-third  to  one-half  of  sudden  deaths  (Breit- 
mann  -^ ) . 

The  usual  gross  heart  lesion  of  late  syphilis  is  aortic  regurgitation^ 
a  lesion  often  associated  with  aortitis,  aortic  aneurysm,  and  disease  of 
the  coronary  arteries.^ 

Aortitis  and  Aneurysm. — Syphilis  is  the  cause  of  practically  all 
aortic  aneurysm,  just  as  it  is  the  cause  of  practically  all  aortic  regurgi- 
tation. The  symptoms  of  inflammation  of  the  aorta  may  be  nil,  or 
there  may  be  attacks  of  cardiac  palpitation  or  angina,  or  persistent  pain 
in  the  left  shoulder,  or  a  dry  cough.  The  Wassermann  reaction  is 
almost  always  positive,  the  x-ray  shows  a  distinct  thickening  of  the 
aorta. 

The  suggestion  that  patients  with  aneurysm  bear  salvarsan  badly 
has  not  been  borne  out  by  experience,  but  the  administration  of  the  drug 
should  be  preceded  by  a  definite  course  of  severe  mercurialization  and 
salvarsan  should  at  first  be  administered  in  small  doses. 

^Berl.  Tclin.  Wochenschr.,  1911,  xlviii,  39. 

*Eecently  pathologic  studies  have  been  published  by  Soprana.  Eiforma  Med., 
May  29,  1915;  Larkin  and  Levy,  N.  Y.  State  Jour,  of  Med.,  1915,  xv,  466. 


CHAPTER    XC 

HEREDITARY  SYPHILIS 

The  modern  syphilograplier  recognizes  no  paternal  or  maternal 
heredity  of  syphilis.  For  him  the  mother  of  every  syphilitic  child  is 
syphilitic,  the  father  may  or  may  not  be  so.-*^  The  infection  is  always 
postconceptional  for  it  is  not  conceivable  that  a  syphilitic  ovum  should 
develop  at  all.  If  the  fetus  is  infected  early  in  pregnancy  it  promptly 
dies  and  an  abortion  occurs  on  the  third  or  fourth  month.  If  later, 
it  is  born  syphilitic,  for  attenuation  of  the  virulence  of  the  spirochetes 
seems  to  occur  within  the  mother.  Untreated  mothers  almost  always 
show  a  succession  of  pregnancies  the  first  one  terminating  in  abortion 
within  a  few  months,  the  succeeding  ones  in  the  birth  of  obviously 
syphilitic  children,  while  the  last  children  to  be  born,  though  they 
usually  develop  syphilis  in  the  later  years  of  life,  may  reach  puberty 
without  any  sign  of  the  disease.  The  problem  involved  has  been  studied 
by  Baisch.^  Fildes  ^  studied  1,000  mothers  and  infants  both  clinically 
and  serologically.  Four  per  cent  of  the  women  gave  a  positive  reaction, 
but  only  1  in  9  of  these  transmitted  the  disease  to  her  child.  Post  * 
has  tabulated  the  early  mortality  from  168  pregnancies  in  30  families. 
There  were  53  still  births  and  44  deaths  within  the  first  year  (a  total 
mortality  o'f  57  per  cent).  Of  the  remaining  71,  39  are  presumably 
healthy,  32  are  kno^vn  to  be  syphilitic.  Hochsinger  ^  has  followed  the 
history  of  263  children  bom  alive  among  his  private  patients  for  from 
4  to  24  years.  Only  14  per  cent  died  during  the  first  year,  while  72 
(25  per  cent)  grew  up  to  be  healthy  adults,  though  21  of  these  were 
scarred  (19  saddle  noses,  17  hyperostoses,  and  7  scarred  lips),  l^one  of 
the  children  with  pronounced  symptoms  soon  after  birth  gTew  up 
healthy.  He  believes  physical,  mental  and  moral  defects  are  com- 
monly due  to  syphilitic  heredity.  The  Wassennann  reaction  is  re- 
markably persistent  even  in  cases  that  show  no  subjective  signs.  If 
the  child  passes  puberty  without  any  manifestations  of  the  disease  it 
is  not  likely  to  be  troubled  during  the  rest  of  its  life.       • 

^  Arch,  of  Pediatrics,  June,  1911. 

^Muenschen.  med.  Wochenschr.,  1909,  Ivi,  1929. 

^  Jour,   of   Ohstet.   ^   Gyn.   of   the  British   Empire,    1915,   xxvii,   124. 

*  Boston  Med.  4'  Surg.  Jour.,  1913,  clxx,  113. 

^Wiener  klin.  WochenscJir.,  June  23,  1910. 

873 


874  HEREDITARY  SYPHILIS 

All  of  tliese  statistics  date  from  the  presalvarsan  period. 
The  important  features  of  hereditary  syphilis  may  be  subdivided  as 
follpws  (Hochsinger)  : 

1.  Fetal  syphilis. 

2.  Infantile  syphilis  (first  three  to  six  months). 

3.  Relapses  in  infancy  (until  the  fifth  year). 

4.  Late  hereditary  syphilis. 

The  importance  of  these  stages  decreases  throughout  the  series. 
Thus  fetal  syphilis  is  fatal  to  about  one-half  the  infected  children.  In- 
fantile syphilis  kills  almost  half  of  the  survivors  in  the  first  three 
months  of  extra-uterine  life.  The  later  relapses  in  infancy  are  less  fre- 
quent, less  severe,  and  rarely  fatal;  while  the  so-called  "late"  or 
"delayed"  hereditary  syphilis,  which  occurs  after  the  fifth  or  sixth  year, 
differs  in  no  respect  from  tertiary  syphilis  in  the  adult.  But  the  adult 
who  has  suffered  hereditary  syphilis  in  infancy  bears  upon  his  body 
certain  evidences  of  the  storm  that  has  passed.  These  form  a  fifth 
division : 

5.  Stigmata  of  hereditary  syphilis. 


FETAL  SYPHILIS 

Pathology — The  pathology  of  fetal  syphilis  differs  from  the  same 
process  in  the  adult  chiefly  in  its  hyperacuteness.  In  the  adult  the  dis- 
ease localizes  itself  here  and  there  in  small  areas  and  shows  a  special 
affinity  to  the  skin  and  mucous  membranes,  and  later  to  the  nervous  sys- 
tem, the  underlying  process  being  always  specific  arterial  disease.  But 
in  the  fetus  the  chief  localizations  are  in  the  viscera,  and  secondly  in 
the  bones ;  the  skin  is  immune  until  just  before  or  just  after  birth. 
Moreover,  the  hyperacuteness  of  the  process  is  shown  in  its  diffusion 
throughout  an  organ,  contrasting  strikingly  with  the  circumscribed  vis- 
ceral involvement  in  the  adult. 

The  viscera  most  frequently  and  most  markedly  affected  are,  in 
order  of  their  importance,  the  lungs,  the  liver,  the  kidney,  and  the 
spleen. 

The  type  of  congenital  syphilis  is  a  diffuse  cell  proliferation  arising  from 
the  perivascular  connective  tissue  of  the  smallest  vessels,  so  that  the  solitary 
syphiloma  is  very  rare  in  the  fetus  and  the  infant. 

The  infiltration  is  exclusivelj'  a  diffuse  one  arising  from  the  smallest  vessels 
in  the  organ,  'with  a  special  tendency  to  later  contraction  and  obliteration  of 
these  vessels.  The  perivascular  proliferation  begins  in  a  sleevelike  way  in 
the  adventitia  and  extends  outward  into  the  connective  tissue,  less  often  Into 
the  inner  wall  of  the  artery,  thus  obliterating  it.  In  all  the  diseased  organs 
one  finds  here  and  there  dense  cell  accumulations  visible  to  the  naked  eye  and 
spoken  of  as  "miliary  syphilomata"  or  "gummata." 


FETAL  SYPHILIS  875 

In  the  affected  organs  wa  find  cheeked  development  of  the  parenchyma, 
abnormal  development  of  the  Malpighian  bodies,  persistent  epithelial  rests  and 
canals,  cystic  development  of  the  cortex  of  the  kidney,  etc.  Thus  the  hyperplasia 
of  the  connective  tissue  goes  hand  in  hand  with  a  hyjjoplasia  of  the  parenchyma. 
These  changes  can  often  not  be  made  out  macroscopically,  and  we  note  only  an 
increase  in  volume  and  density  of  the  liver  and  spleen  (Hochsinger). 

The  placenta  usually  shows  changes  similar  to  those  in  the  fetal 
viscera.  Both  the  maternal  and  fetal  portions  of  the  placenta  show  the 
diffuse  perivascular  infiltration,  so  that  the  placenta  is  more  volu- 
minous and  heavier  than  normal  (it  may  reach  one-fourth  or  one- 
third  the  weight  of  the  child)  ;  the  cord  is  also  hard  and  considerably 
enlarged. 

Symptoms. — The  fetus  affected  with  syphilitic  visceral  lesions  may 
come  to  one  of  three  ends,  as  follows : 

1.  It  may  be  aborted  or  still-bom. 

2.  It  may  be  born  manifestly  syphilitic. 

3.  It  may  be  born  apparently  healthy. 

1.  The  death  of  the  fetus  in  uterc  is  often  caused  by  hydramnia,  de- 
pending upon  syphilitic  phlebitis  of  the  cord ;  or  by  inanition  from  over- 
whelming visceral  disease.  Abortion  usually  occurs  between  the  fourth 
and  the  seventh  month,  and  the  fetus  thus  aborted  is  usually  dead  and 
macerated.  Monstrosities  are  said  to  be  relatively  frequent  because  of 
the  interference  with  placental  circulation. 

2.  The  typical  syphilitic  infant  presents  a  picture  of  pseudosenility 
— ^thin,  feeble,  marantic,  with  a  dull,  cafe  au  lait  color,  a  wrinkled,  loose 
skin,  upon  which,  even  at  birth,  there  may  be  an  eruption;  with  the 
snuffles,  with  a  hoarse  cry,  with  sunken  and  inflamed  eyes,  and  perhaps 
with  pseudoparalysis  or  some  lesion  of  the  nervous  system,  the  unfor- 
tunate infant  forms  a  horrible  picture  of  the  ravages  of  hereditary 
syphilis. 

3.  But  the  child  with  syphilitic  lesions  of  the  viscera  may  he  horn 
seemingly  in  good  he-alth.  Among  the  syphilitic  infants  born  alive  rela- 
tively few  present  so  marked  a  picture  of  the  disease.  ISTot  only  may 
the  infant  be  born  with  no  actual  syphilitic  lesions  apparent,  but  he 
may  be  in  good  condition.  The  skin  is  likely  to  be  lacking  in  pinkness 
and  fullness  and  the  infant  rather  under  weight.  Thus  Tarnier,  among 
52  syphilitic  children,  found  14  of  nonual  weight  (above  3,250  gTa.) 
and  38  below  it  (Hochsinger),  while  Vas  ^  found  that  even  breast 
feeding  did  not  keep  them  up  to  normal. 

The  direct  evidence  of  the  syphilitic  visceral  lesions  is  the  en- 
largement of  spleen  and  liver  or  of  the  pseudoparalysis  from  osteo- 
chondritis. 

^  Jahrb.  f.  Kinderheilk.,  Apr.,  1912. 


876  HEREDITARY  SYPHILIS 

INFANTILE  SYPHILIS 

AlthougK  tlie  lesions  presented  by  the  infant  witli  hereditary  syph- 
ilis are  due  to  precisely  the  same  protozoal  cause  as  those  in  the  adult, 
they  are  markedly  dissimilar.  Thus  we  have  seen  that,  in  the  fetus,  the 
viscera  are  the  chief  points  of  attack.  In  the  infant  the  disease  first 
strikes  the  mucous  membrane  of  the  nose,  producing  snuffles,  and  then 
shows  itself  by  lesions  upon  the  skin ;  but  these  skin  lesions  are  not  the 
same  in  character  as  those  of  early  syphilis  in  the  adult,  nor  are  they 
by  any  means  constant. 

Intermingled  with  these  symptoms,  or  succeeding  them,  there  may 
be  evidences  of  bone  or  visceral  disease,  or  the  little  patient  may  show 
his  malady  simply  by  his  thinness,  his  slow  gain  in  weight,  and  his  rest- 
lessness. 

Taking  up  the  early  symptoms  in  order  of  clinical  importance,  we 
shall  discuss : 

Inflammation  of  the  nose. 

Inflammation  of  the  skin. 

Inflammation  of  the  bones,  joints,  and  muscles. 

Inflammation  of  the  viscera. 

Mixed  "infection"  (pyogenic  or  tuberculous). 

Syphilitic  dystrophies. 


INFLAMMATION  OF  THE  NOSE 

"Snuffles"  is  the  earliest  and  most  constant  symptom  of  hereditary 
syphilis,  and  one  of  the  least  characteristic.^  The  symptom  is  not  quite 
that  of  snuffles  in  an  older  child,  for  at  first  there  is  little  or  no  running 
from  the  nose,  but  only  an  obstruction  to  nasal  respiration  which  makes 
the  child  breathe  in  a  characteristic  snuffly  way  and  gravely  interferes 
with  nursing. 

Hochsinger  has  tabulated  65  cases,  of  which  38  began  at  birth,  15 
in  the  first  month,  and  12  later  than  the  first  month. 

The  inflammation  begins  as  hypertrophy  of  the  nasal  mucous  mem- 
brane, at  first  a  dry  congestion  beginning  in  the  lower  part  of  the  nose, 
which  soon  goes  on  to  ulceration  and  causes  a  profuse  mucous  discharge, 
often  tinged  with  blood;  epistaxis  is  most  exceptional.  The  discharge 
is  acrid,  and  excoriates  the  upper  lip.  Perforation  of  the  septum  is 
rare  in  infancy  but  the  development  of  the  nasal  bones  is  impaired 
or  arrested  and  the  bridge  of  the  nose  left  sunl-cen  in  a  characteristic 
manner   (later  relapses  of  hereditary  syphilis  of  the  nose  commonly 

*ror  it  may  be  due  to  many  causes. 


INFLAMMATION  OF  THE  SKIN 


!Y7 


cause  perforation).    Hence  the  nasal  deformity  so  suggestive  of  syphilis 
(Fig.  203). 

The  first  clinical  evidence  of  this  nasal  disease  is  restlessness,  due 
to  the  fact  that  the  little  patient  cannot  sleep  because  of  the  difficulty 
of  breathing  through  its  stopped  up  nose.  The  snuffly  breathing  soon 
follows,  and  the  infant,  being  unable  to  breathe  through  its  nose,  may 
be  almost  totally  unable  to  nurse;  its  attempts  at  suckling  and  swallow- 
ing being  frustrated  by  the  rapidly  recurring  need 
of  breathing,  so  that  the  process  becomes  a  disheart- 
ening series  of  gasps,  chokings,  and  regiirgitations, 
which  result  in  the  ingestion  of  little  or  no  nourish- 
ment. Thus  this  relatively  insignificant  lesion  may 
be  the  chief  cause  of  a  grave  impairment  of  nutri- 
tion. 


INFLAMMATION  OF  THE  SKIN 

The    striking    characteristics    of    the    first    skin 
lesions  of  hereditary  syphilis  are: 

1.  Polymorphism. 

2.  Regional  distribution. 

3.  Confluence. 
Most  of  the  lesions  are  papular  or  maculopapu- 

lar,  while  an  occasional  macule  may  be  seen.  The 
papular  eruption  of  hereditary  syphilis  is  quite  com- 
parable to  that  of  acquired  syphilis,  except  that  it  is 
commonly  intermingled  with  lesions  of  a  macular 
character,  and  is  itself  often  confluent. 

Polymorphism — On  account  of  the  tenderness  of 
the  skin  this  papulomacular  eruption  very  readily  takes  on  secondary 
changes.    In  dry  regions  the  lesions  tend  to  become  squamous,  or,  if  the 
eruption  is  severe,   bullous  or  pustular;   while  in  moist  regions  the 
lesions  are  confluent,  erosive,  ulcerated,  or  condylomatous. 

Regional  Distribution. — The  eruption  usually  appears  about  the 
genitals,  the  buttocks,  the  flexor  surfaces  of  the  thighs,  upon  the  palms 
and  soles,  and  upon  the  lips  and  chin.  The  scalp,  arms,  and  legs  are 
somewhat  less  frequently  affected,  while  the  upper  part  of  the  trunk 
above  the  line  of  the  diaper  is  relatively  immune,  doubtless  because  it  is 
the  dryest  and  thickest  skin  upon  the  infant's  body. 

Confluence. — The  marked  tendency  to  confluence  shown  by  the  early 
skin  lesions  of  hereditary  syphilis  is  due  to  the  tenderness  of  the  skin 
and  the  difficulty  in  keeping  it  clean;  hence  the  confluent  lesions  are 
usually  seen  under  the  diaper,  in  various  moist  creases  of  th-e  body,  and 
about  the  mouth  . 


Fig.    203.  — Syphil- 
itic Nose. 


878  HEREDITAEY  SYPHILIS 

It  is  convenient  clinically  to  distinguisli  four  types  of  lesions : 

1.  Pempliigiis. 

2.  Circumscribed  or  diffuse  maculopapular  syphilid  (see  above). 

3.  Lesions  of  special  regions. 

4.  Tubercular  or  gTumnatous  syphilid. 

PEMPHIGUS 

The  earliest,  one  of  the  rarest,  and  the  most  ominous  skin  lesion  of 
hereditary  syphilis  is  pemphigus,  or  the  bullous  syphilid.  It  appears 
before  birth  or  in  the  first  week  of  extra-uterine  life,  less  often  in  the 
two  or  three  weeks  following.  Its  typical  situation  is  upon  the  palms 
and  soles,  whence  it  may  spread  over  the  rest  of  the  body. 

The  eruption  consists  of  large,  copper-colored  papules,  upon  which 
are  set  flaccid  blebs  containing  serum  and  pus  or  blood.  As  these  rup- 
ture they  leave  an  eroded  surface ;  or,  if  the  ulceration  is  deep,  greenish 
scabs  take  the  place  of  the  ruptured  bullae.  When  this  eruption  occurs 
before  the  second  week  of  extra-uterine  life  it  is  an  accepted  sign  that 
the  child  will  die. 

Diagnosis. — It  may  be  readily  distinguished  from  the  pemphigus 
neonatorum,  which  never  occurs  before  the  second  week,  and  usually 
much  later,  is  often  epidemic,  occurs  upon  otherwise  healthy  children, 
and  only  most  exceptionally  appears  upon  the  palms  and  soles. 

LESIONS    OF     SPECIAL    REGIONS 

Erosions  of  the  Lips. — Eroded  mucous  papules  are  very  common 
upon  the  vermilion  border  of  the  lips,  and  are  promptly  fissured  and 
transformed  into  deep-red,  oozing  cracks,  surrounded  or  covered  by 
a  little  crust.  They  are  usually  multiple,  and  are  commonest  at  the 
angle  of  the  mouth.  They  are  extremely  painful,  and  interfere  gravely 
with  suckling.  As  they  heal  they  leave  radiating  linear  scars  upon 
the  lips,  which  in  later  years  form  one  of  the  most  striking  and  reliable 
stigmata  of  hereditary  syphilis. 

Anogenital  Lesions. — These  are  usually  associated  with  dry  or 
scaly  papules  elsewhere  in  the  body,  and  are  themselves  confluent, 
erosive,  or  ulcerated,  rarely  condylomatous,  and  still  more  rarely  pus- 
tular. But  in  the  relapses  of  early  childhood  condylomata  are  very 
common. 

Onychia  and  Paronychia — The  typical  nail  of  the  syphilitic  infant 
is  raised  high  in  the  center  and  depressed  laterally,  as  though  it 
had  been  pinched  by  a  forceps.  It  resembles  a  claw  rather  than  a  nail. 
The  condition  usually  affects  all  the  nails.  Such  nails  are  often  under- 
mined by  paronychia,  so  that  they  are  readily  detached. 


INFLAMMATION  OF  THE  BONES  879 

Lesions  of  the  Scalp. — The  moth-eaten  poll  is  quite  uncommon  in 
infancy,  and  more  extensive  baldness  (which  has  the  same  characteris- 
tics as  in  the  adult)  very  rare. 

The  papular  eruption  upon  the  scalp,  instead  of  forming  small,  dis- 
seminated, crusted  lesions,  as  in  the  adult,  may  produce  an  extensive 
incrustation  closely  simulating  eczema ;  but  removal  of  the  syphilitic 
scab  leaves  an  intact,  though  infiltrated,  area  beneath  it,  while  removal 
of  an  eczematous  crust  leaves  the  malpighian  rete  exposed. 

TUBERCULAR  AND  GUMMATOUS  SYPHILID 

It  is  not  always  possible  to  distinguish  between  a  furuncle  and  a 
syphilitic  tubercle  or  gaimma ;  indeed,  these  lesions  are  classed  as  "f ur- 
uncular  syphilids"  by  Taylor,  while  their  syphilitic  nature  is  entirely 
denied  by  Jacquet.  They  are,  however,  accepted  by  most  authorities, 
and  Carpenter  states  that  among  364  syphilitic  eruptions  seen  by  him 
during  the-  first  year  of  life  there  were  70  cutaneous  gummata,  34  of 
which  were  associated  with  other  lesions  of  the  skin. 

The  lesion  is  a  syphilitic  tubercle  or  a  subcutaneous  gTimma;  it 
often  becomes  pustular,  and  so  remains  for  a  considerable  time  before 
ulcerating. 

LESIONS  OF  THE  MUCOUS  MEMBRANE 

Excepting  the  nose,  the  lips,  and  the  anus,  lesions  of  the  mucous 
membrane  are  extremely  rare.  The  ulcers  that  occur  in  the  mouth  are 
alleged  by  many  authors  to  be  aphthous,  not  truly  syphilitic. 

Aplionia  is  frequent,  however,  due  to  infiltrative  and  ulcerative 
laryngeal  lesions  similar  to  those  seen  in  the  adult.  The  familiar 
"hoarse  cry"  of  the  syphilitic  infant  is  quite  as  suggestive  and  far  more 
common  than  the  hoarse  voice  of  the  syphilitic  adult. 

The  intestine  may  be  inflamed,  and  show  post  mortem  a  diffuse 
thickening  of  the  mucous  membrane  with  ulceration. 


INFLAMMATION  OF  THE  BONES 

While  any  of  the  lesions  of  bone  that  occur  in  the  adult  may  also 
occur  in  hereditary  syphilis,^  the  two  striking  and  distinctive  char- 
acteristics of  bone  syphilis  in  the  infant  are  osteochondritis  and 
periostitis.    - 

Osteochondritis — Mild  syphilitic  osteochondritis,  causing  slight 
distortion  and  enlargement  of  the  bone  at  the  epiphyseal  line,  is  very 

'  Cf .  Fitzwilliams,  Brit.  Jour.  Children's  Bis.,  March,  1912. 


880  HEREDITARY  SYPHILIS 

common.  Its  lesions  can  be  accurately  studied  only  by  tbe  x-ray.  It 
appears  almost  always  in  the  first  six  months. 

The  knee  and  the  elbow  are  most  commonly  and  most  markedly  af- 
fected and  the  lesion  consists  in  a  syphilitic  infiltration  of  the  diaphysis 
at  its  junction  with  the  epiphysis,  which  results  in  a  thickening  of  the 
bone  at  this  point  and  a  marked  irregularity  at  this  line  of  junction. 
Very  rarely  this  lesion  progresses  so  far  that  the  gTanulomatous  tissue, 
disintegrating  the  epiphyseal  cartilage,  produces  an  epiphyseolysis. 
This  rare  lesion,  appropriately  called  "syphilitic  pseudoparalysis  of  the 
new-bom,"  usually  affects  the  elbow  and  is  congenital ;  it  may  be  poly- 
articular. 

Periostitis. — The  periosteal  lesions  of  early  syphilis  are  usually 
most  marked  upon  the  skull,  though  similar  lesions  may  affect  any 
bone.     They  are  seldom  encountered  before  the  fourth  year. 

The  lesions  of  syphilis  in  the  skull  are,  in  order  of  frequency: 
infiltration  and  softening  between  the  tables  and  in  the  sutures ;  diffuse 
periostitis  of  the  frontal  or  parietal  bosses,  causing  an  enlargement 
which,  if  frontal,  produces  the  so-called  "Olympian"  brow;  if  lateral, 
a  considerable  widening  of  the  transverse  diameter  of  the  skull  (nati- 
form  skull).  Less  frequent  is  the  rarefying  ostitis  with  tendency  to 
gummatous  degeneration.  Finally,  the  skull  may  be  affected  second- 
arily by  hydrocephalus. 

American  authorities  consider  it  unsafe  to  accept  cranial  deformities 
as  evidence  of  hereditary  syphilis  unless  supported  by  other  typical 
signs.  Parrott's  nodes  and  craniotabes,  though  sometimes  spoken  of  as 
syphilitic,  are  actually  of  rachitic  origin. 

Dactylitis. — Dactylitis  is  less  uncommon  in  hereditary  than  in 
acquired  syphilis.  It  occurs  after  the  first  year.  It  never  affects  the 
feet  (Fitz Williams). 


INFLAMMATION  OF  THE  VISCERA  AND  OTHER  ORGANS 

Lymph  Nodes. — Lymphadenitis  is  not  typical  of  hereditary  syphilis. 
Marked  epitrochlear  adenitis  is  of  some  diagnostic  importance.  The 
presence  of  other  enlarged  nodes  is,  as  a  rule,  directly  attributable  to 
adjacent  lesions. 

Testicle — Syphilitic  sclerosis  of  the  testicle  is  extremely  common 
in  still-born  children.     It  is  rare  in  those  that  survive. 

Inasmuch  as  the  size  of  the  testicle  in  infancy  varies  between  wide 
limits,  while  syphilis  of  the  organ  often  does  not  greatly  alter  its  size, 
the  clinical  manifestation  of  the  lesion  is  usually  an  increase  in  hard- 
ness, which  may  be  masked  by  hydrocele.  Testis  and  epididymis  may 
be  involved  separately  or  together.    The  lesion  usually  leads  to  atrophy 


INFLAMMATION  OF  VISCERA  AND  OTHER  ORGANS  881 

of  the  testicle,  and  great  stress  is  laid  bj  certain  authors  upon  the  ex- 
istence of  this  atrophy  in  adult  years  as  an  evidence  of  hereditary 
syphilis. 

Diagnosis. — Inasmuch  as  tuberculosis  of  the  testicle  may  occur 
shortly  after  birth  (Dreschfield  has  recorded  a  congenital  case),  and 
produce  lesions  macroscopically  similar  to  those  of  syphilis,  the  diag- 
nosis should  be  confirmed  by  a  Wassermann  reaction. 

Liver  and  Spleen — Hereditary  syphilis  of  the  liver  and  spleen 
are  so  intimately  associated  that  it  seems  proper  to  consider  them  as 
one.  Syphilitic  changes  may  be  found  in  these  organs  in  many  instances 
post  mortem,  although  no  evidence  of  such  disease  v^as  apparent  dur- 
ing life. 

The  pathological  changes  have  already  been  described. 

Clinically,  the  manifestation  of  these  lesions  consists  in  an  enlarge- 
ment of  the  affected  organs.  This  enlargement  is  noted  in  30  per  cent 
to  40  per  cent  of  cases  in  the  first  three  months  of  life ;  and  in  almost 
every  instance  enlargement  of  the  spleen  implies  enlargement  of  the 
liver,  and  vice  versa.^  The  enlargement,  though  usually  slight,  may  be 
considerable,  and,  exceptionally,  one  may  identify  thickening  of  the 
edge  and  irregxilarity  of  the  outline  of  the  liver,  as  in  acquired 
syphilis. 

Syphilitic  jaundice  is  extremely  rare  in  early  infancy.  Ascites 
does  not  occur  until  a  later  age. 

Lungs — The  lesions  are  so  commonly  fatal  that  they  can  scarcely 
be  said  to  give  any  clinical  manifestations. 

Nervous  System. — Restlessness  and  sleeplessness  are  striking  symp- 
toms of  early  hereditary  syphilis,  and  have  been  referred  to  meningeal 
irritation,  but  are  more  often  due  to  nasal  obstruction.  Though  these 
early  cases  may  show  post  mortem  lesions  throughout  the  nervous  sys- 
tem, they  show  during  life  no  evidence  of  peripheral  neuritis  or  of 
syphilis  of  the  cord ;  while  symptoms  of  syphilitic  meningitis  other  than 
restlessness,  sleeplessness,  and  convulsions  are  extremely  rare.  The  only 
exception  is  hydrocephalus.  This,  whether  acute  or  chronic,  internal 
or  external,  is  often  syphilitic,  and  develops  with  the  first  outbreak  of 
symptoms   (in  the  first  or  second  month). 

Eye — Lesions  of  the  eye  are  extremely  rare  at  this  early  date. 

Ear. — Extension  of  the  nasal  catarrh  to  the  middle  ear,  resulting 
in  acute  otitis  media,  is  not  uncommon. 

^  Iloclisinger  found  that  splenic  enlargement  accompanied  hepatic  enlarge- 
ment in  44  out  of  46  cases.  He  also  states  that  only  3  per  cent  of  the  infants 
showing  enlargement  of  the  spleen  were  not  syphilitic.  Carpenter  states  that 
when   the   spleen  is  enlarged  the  liver  is  also   enlarged  in  four-fifths  of  the  cases. 


882  HEREDITARY  SYPHILIS 

MIXED   INFECTION 

As  a  frequent  and  grave  complication  of  early  hereditary  syphilis 
it  shows  itself  chiefly  in  four  types: 

1.  Mixed  infection  of  the  skin. 

2.  Mixed  infection  of  the  respiratory  tract. 

3.  Mixed  infection  of  septic  type. 

4.  Tuberculosis  and  rachitis. 

Skin. — Mixed  infection  of  the  skin  shows  itself  in  the  frequency  of 
pustular  and  ulcerating  lesions,  while  pseudofurunculosis  is  due  in 
most  instances  to  pyogenic  bacteria. 

Respiratory  Tract. — The  discharges  of  syphilitic  coryza  swarm 
with  all  manner  of  bacteria.  Hence  the  inflammation  may  spread  to 
the  ear,  causing  otitis  media,  or  to  the  lung,  causing  bronchopneumonia. 
This  latter  complication  accounts  for  many  deaths. 

Sepsis — The  petechiae  and  other  hemorrhagic  skin  lesions  that 
occur  in  certain  malignant  cases  of  early  hereditary  syphilis  are,  doubt- 
less, evidences  of  acute  septicemia. 

Tuberculosis  and  Rachitis. — The  relation  between  rachitis  and  syph- 
ilis has  long  since  been  determined.  Parrott  believed  and  taught  that 
every  rachitic  child  was  syphilitic;  but  subsequent  investigation  has 
clearly  shown  that  this  is  not  the  case,  that  syphilis  is  only  one  among 
many  potential,  debilitating  causes  of  rickets. 

The  same  is  true  of  tuberculosis.  Sergent  ^  has  recently  collected 
much  evidence  in  the  matter,  and,  with  a  wealth  of  authoritative  quota- 
tions, enforces  his  conclusions  that  "la  syphilisoiion  du  pere  a  pre- 
pare le  terrain  pour  la  tuberculisation  du  fils" — syphilis  in  the  father 
prepares  the  soil  for  tuberculosis  in  the  son. 

This  aphoristic  statement  expresses  the  actual  condition  not  quite 
accurately.     It  is  necessary  to  distinguish  as  follows : 

1.  Syphilis  in  the  father,  if  severe  or  if  allied  with  other  debilitat- 
ing influences,  such  as  drink,  deprivation,  or  debauch,  prepares  the 
father's  own  soil  for  tuberculosis. 

2.  Syphilis  transmitted  from  parent  to  child — hereditary  syphilis 
— exercises  the  same  predisposing  influence  magnified  by  the  diffi- 
culty of  eradicating  the  disease  from  the  vulnerable  tissues  of  the 
new-born. 

3.  But  the  nonsyphilitic  child  of  a  syphilitic  parent  is  not  predis- 
posed to  tuberculosis,  unless  by  such  privation  or  neglect  as  would  so 
predispose  it  in  any  event. 

Although  tuberculosis  and  rachitis  are  frequently  attendant  upon 
syphilis  a  little  later  in  life,  they  scarcely  figure  in  the  first  few  months. 
^"Syphilis   et   tuberculose, "   Paris,    1907. 


A 


LATE  HEREDITARY  SYPHILIS  883 


SYPHILITIC  DYSTROPHIES 


The  interference  witii  nutrition  due  to  hereditary  syphilis  shows 
itself  in  two  ways:  First,  and  most  frequently,  by  killing  the  child 
within  a  few  days  of  its  birth ;  secondly,  by  impairing  its  nutrition,  bnt 
not  killing  it. 

The  first  evidence  of  impaired  nutrition  may  be  the  puny,  decrepit 
state  of  the  child  at  birth ;  or  it  may  be  born  apparently  healthy,  and 
promptly  lose  weight  and  strength  in  spite  of  a  good  digestion  and  an 
abundant  supply  of  mother's  milk.  Such  infants,  though  they  may  sur- 
vive for  a  time,  are  carried  off  either  by  the  cachexia  of  the  disease  itself 
or  by  such  complications  as  convulsions,  diarrhea,  or  bronchopneumonia 
during  the  first  year  of  their  lives. 

From  these  various  causes  something  like  nine  out  of  ten  bottle-fed 
or  hospital  babies  fail  to  survive,  though  in  private  practice  hygiene, 
human  milk,  and  intelligent  medical  care  cut  down  the  mortality  con- 
siderably. 

But  beyond  this  obviously  syphilitic  toxemia  there  is  a  set  of  vague 
conditions,  such  as  go  to  produce  congenital  deformities — e.  g.,  club- 
foot, harelip,  etc. — or  to  arrest  development,  causing  the  child  to  attain 
puberty  very  late,  to  have  sex  characteristics  but  slightly  developed, 
and  to  remain  childish  both  in  mind  and  body.  Idiocy  and  epilepsy  are 
said  to  be  exceptionally  frequent  in  otherwise  apparently  healthy  chil- 
dren of  syphilitic  parents   (Lippmann^). 

In  how  much  these  conditions  are  due  to  a  real  syphilis  of  the  child 
and  in  how  much  to  an  inherited  tendency  from  the  parent  (similar  to 
that  of  alcoholism,  for  instance)  it  is  difficult  to  say. 


LATE  HEREDITARY  SYPHILIS 

From  the  sixth  to  the  eighth  year,  and  again  at  about  the  time  of 
puberty,  hereditary  syphilis  may  relapse;  relapses  excepting  at  these 
times  are  infrequent. 

The  arbitrary  limit  of  twenty-six  years  set  by  Fournier  for  the 
duration  of  hereditary  syphilis  is,  in  general,  the  extreme  limit ;  in- 
deed, lesions  after  puberty  are  extremely  rare. 

The  active  syphilitic  lesions  of  late  hereditary  syphilis  are,  with  but 
very  few  exceptions,  quite  the  same  as  those  that  occur  in  late  acquired 
syphilis.  They  are,  in  other  words,  the  tertiary  lesions  of  the  disease 
occasionally  intermingled,  as  in  acquired  syphilis,  M'ith  certain  late  sec- 
ondaries, especially  those  of  the  palms,  the  soles,  and  the  tongue.     Cer- 

^  Muench.  med.  Wochenschr.,  Nov.  23,  1909. 


884  HEREDITARY  SYPHILIS 

tain  classes  of  lesions  are,  however,  somewliat  more  common  in  late 
hereditary  than  in  late  acquired  syphilis.  Such  are  the  various  lesions 
of  the  eye,  deafness  from  internal  ear  disease,  perforation  of  the  septum 
and  palate,  and  diffuse  periostitis  of  the  long  bones.  The  joints  are 
relatively  often  affected,  and  the  danger  of  mistaking  a  pseudotubercu- 
lar  syphilitic  knee  in  the  young  for  the  tubercular  "white  swelling" 
must  be  borne  in  mind.    Interstitial  keratitis  is  not  uncommon. 

Tabes  and  Paresis. — Tabes  and  paresis  due  to  hereditary  syphilis 
occur  at  about  the  time  of  puberty.  The  first  sign  of  tabes  is  usually 
enuresis  (Spitzmueller),  while  delusions  characterize  paresis. 


STIGMATA  OF  HEREDITARY  SYPHILIS 

The  stigmata  of  hereditary  syphilis  are  the  scars  of  syphilitic  lesions 
or  the  deformities  or  peculiarities  in  development  left  by  syphilitic 
lesions  occurring  in  infancy  or  in  youth.  They  are  more  or  less  charac- 
teristic of  the  disease,  though  only  the  radiating  fissures  of  the  lips 
and  the  typical  saher  tibia  are  absolutely  pathognomonic.  Yet  many  of 
them  are  presumptive  evidence  of  the  greatest  importance. 

Only  the  important  stigmata  need  be  described. 

The  chief  stigmata  of  hereditary  syphilis  may  be  classed  as  follows  : 

1.  Hutchinson's  triad,  consisting  of  dental,  ocular,  and  auditory 
stigmata. 

2.  Bone  stigmata. 

3.  Skin  stigmata. 

4.  Visceral  stigmata. 

5.  Constitutional  stigmata. 

Of  these,  the  first  three  are  of  prime  importance,  the  two  last  are 
rarer  and  less  characteristic. 

The  chief  bone  stigmata  are  found  in  the  skull  (frontal  or  lateral 
bosses^  asymmetry  and  irregular  development,  hydrocephalus),  in  the 
nose  (sunken  bridge),  and  in  the  long  bones  (diffuse  periostitis,  saber 
tibia,  and  such  scars  of  epiphyseitis  as  epiphyseal  enlargements,  and 
arrested  or  excessive  growth  of  the  bone).  The  skin  stigmata  do  not 
differ  from  those  of  acquired  syphilis,  excepting  the  important  lip  fis- 
sures. The  only  notable  visceral  stigmata  are  atrophy  of  the  testicle  and 
parenchymatous  keratitis.  The  constitutional  stigmata  consist  of  a 
gray,  bloodless  skin  and  a  slowness  of  physical  and  intellectual  develop- 
ment that  may  amount  to  "infantilism"  or  idiocy. 

Diffuse  Periostitis. — The  periosteal  changes  of  late  hereditary  syph- 
ilis are  the  same  as  those  of  acquired  syphilis  excepting  in  their  dis- 
tribution.    The  hereditary  lesions  are,  however,  often  much  more  dif- 

"■Med.  Klin.,  Jan.  23,  1910. 


STIGMATA  OF  HEREDITARY  SYPHILIS 


885 


fuse  than  the  acquired  ones,  sometimes  extending  over  the  whole  length 
of  a  long  bone.  This  diffuse  process  is  most  common  in  the  tibia,  to 
which  it  imparts  a  peculiar  and  pathognomonic  form.  The  shaft  of  the 
bone  is  thickened  in  all  its  diameters,  but  especially 
anteroposteriorly ;  so  that,  at  first  glance,  the  bone 
appears  to  be  bowed  forward;  but  palpation  reveals 
that  this  bowing  is  simply  a  thickening  around  it  of 
new  bone  without  any  deviation  in  its  axis  (Fig. 
201). 

HUTCHINSON'S  TRIAD 

Most  important  among  the  stigTaata  of  hereditary 
syphilis  are  those  lesions  grouped  as  a  triad  by  Jona- 
than Hutchinson,  Sr.,  from  whom  they  very  appro- 
priately derive  their  title. 

"Hutchinson's  triad"  is  commonly  taken  to  mean 
the  association  of — 

1.  Notched  and  pegged  upper,  central,  perma- 
nent incisors. 

2.  Interstitial  keratitis  or  the  scar  thereof,  and 

3.  Nerve  deafness. 
But  though  these  three  are  the  most  striking  of 

the  lesions  in  question,  it  is  preferable  to  employ  the 
term  in  a  looser  sense  to  cover  all. 

1.  Dental  stigmata, 

2.  Ocular  stimata,  and 

3.  Aural  stigmata. 

Dental  Stigmata— The  dental  stigmata  of  hered- 
itary syphilis  are  due  to  arrested  development  of  the 
teeth  in  the  process  of  formation.  Permanent  in- 
cisors and  the  sixth-year  molars  are  the  teeth  most 
often  affected  because  they  are  in  process  of  forma- 
tion during  the  first  three  months  of  extrauterine 
life — i.  e.,  at  the  very  time  when  hereditary  syphilis 
shows  its  greatest  virulence. 

Hereditary  syphilis  may,  however,  impart  to  the 
teeth  almost  any  malformation  in  size,  position,  and 
shape.  Fournier,  who  has  made  a  special  study  of 
this  matter,  describes  some  ten  varieties  of  syphilitic 
dental  deformities. 

Hutchinson's  Teeth. — This  deformity,  though 
not  peculiar  to  any  tooth,  is  usually  confined  to  the  permanent  upper, 
median  incisors.     It  is  not  absolutely  pathogTiomonic  of  syphilis. 

Typical  Hutchinson's  incisors  are  abnormally  small,  pegged  (i.  e., 


Fig.  204.  —  Pezzer 
Self  -  retaining 
Catheter. 


886  HEREDITARY  SYPHILIS 

tapering  inward  from  above  downward),  and  show  a  peculiar  erosion 
of  the  free  border.  This  erosion  forms  an  absohitely  regular  crescentic 
bevel  of  the  anterior  surface  of  the  free  border  of  the  tooth.  When  the 
tooth  erupts,  its  free  border  is  quite  rough,  but  this  roughness  rapidly 
wears  away,  leaving  a  typical  Hutchinson's  tooth,  which  retains  its 
characteristics  for  some  fifteen  or  twenty  years.  But  by  the  time  the 
patient  reaches  the  age  of  twenty  or  twenty-five  the  bevel  edge  is  all 
worn  off.  Hutchinson's  teeth  are  almost  always  symmetrically  bilateral, 
and  affect  the  permanent,  upper,  central  incisors,  which  are  often  some- 
what displaced,  usually  converging  toward  each  other, 

Foueniee's  Teeth. — Fournier  has  described  a  less  characteristic 
deformity  of  the  sixth-year  molar,  which  he  says  is  even  more  common 
than  Hutchinson's  teeth. 

The  deformity  consists  in  an  erosion  of  the  summit  of  the  tooth. 
About  three-fourths  of  the  tooth  is  entirely  normal;  the  terminal 
fourth  "is  diminished  in  all  its  diameters,  irregular,  eaten,  as  though 
atrophied,  and  separated  from  the  healthy  part  by  a  circular  ridge." 
After  five  or  ten  years  of  use  this  eroded  crown  wears  away,  leaving  a 
short  tooth  with  a  smooth  top,  to  which  Foumier  attaches  considerable 
diagnostic  sigTiificance. 

Parenchymatous  Keratitis — Parenchymatous  keratitis,  though  it 
may  occur  in  the  first  months  of  extra-uterine  life  or  even  before  birth 
(Parinaud),  and  as  late  as  the  thirty-sixth  year  (Hugiienin),  is  com- 
mon only  between  the  eighth  and  the  fifteenth  year  (Hutchinson).  It 
is  one  of  the  frequent  manifestations  of  hereditary  syphilis,  occurring 
very  frequently  (59  per  cent,  according  to  HugTienin).  On  the  other 
hand,  it  is  not  absolutely  pathognomonic  of  syphilis.  Though  Hutchin- 
son places  great  weight  upon  it  as  a  diagnostic  sign,  careful  investiga- 
tion reveals  other  evidences  of  syphilis  in  not  much  more  than  one-half 
the  cases  (36  per  cent,  according  to  Alexander;  55  per  cent,  according 
to  Michel).  Hence  it  is  not  of  itself  an  absolute  proof  of  the  existence 
of  syphilis.     Interstitial  keratitis  may  occur  in  acquired  syphilis. 

Auditory  Stigmata — Deafness  may  result  either  from  lesions  of 
the  middle  ear  or  from  those  of  the  inner  ear  or  of  the  nerve.  Middle- 
ear  deafness  is  only  indirectly  due  to  syphilis,  and  is  much  more  often 
due  to  other  causes.  But  internal  ear  or  "nerve"  deafness  in  children 
or  young  persons  is  almost  exclusively  due  to  syphilis. 


TREATMENT  IN  INFANCY 

Prophylaxis  by  thorough  salvarsanization  of  the  syphilitic  mother 
before  the  fourth  month  of  gestation  is  practically  certain  to  save  the 
fetus  from  infection.     Later  in  pregnancy  it  may  succeed. 


TREATMENT  IN  INFANCY  887 

The  treatment  of  liereditary  syphilis  is  based  upon  the  same  iiiles 
as  is  that  of  acquired  syphilis,  with  the  important  difference  that  our 
hygienic  efforts  are  confined  almost  solely  to  the  matter  of  diet,  mother's 
milk  being  quite  as  important  as  doctor's  mercury. 

The  Wassermann  reaction  is  done  on  blood  obtained  from  the 
child's  back  by  scarification  and  cupping.  The  suction  must  be  gentle 
for  fear  of  breaking  up  the  red  blood  cells. 

Salvarsan  is  given  intravenously  on  the  same  principles  as  to  the 
adult.  The  accepted  dose  is  0.01  gm.  per  kilogram  of  body  weight. 
To  infants  it  may  be  administered  in  a  vein  of  the  scalp  or  in  the 
external  jugular  (while  the  child  is  crying). 

The  duration  of  routine  treatment  in  infancy  should  cover  the  first 
two  years,  just  as  in  adult  life.  A  very  brief  treatment  may  suffice 
to  quell  the  disease.  But  it  is  the  part  of  wisdom  to  clinch  the  ad- 
vantage gained  by  a  course  similar  to  that  employed  for  the  adult  and 
covering  the  first  two  years.  In  infancy,  however,  the  following  rule 
applies : 

Mercury  may  be  given  by  injection  or  by  inunction.  Intramuscular 
injections  have  found  little  favor,  though  the  employment  of  both  the 
soluble  and  the  insoluble  salts  has  been  urged. 

The  usual  treatment  consists  in  the  application  of  the  officinal  ung. 
hydrargyri,  diluted  with  two  or  three  parts  of  vaselin  (reducing  it  to 
one-third  or  one-quarter  strength).  This  is  laid  on  the  belly  band  and 
renewed  with  it.  Xo  special  precautions  need  be  taken  to  prevent  irri- 
tation of  the  skin,  and  the  application  may  be  continued  daily  through- 
out the  treatm.ent  with  only  such  intermissions  as  may  be  required  by 
the  appearance  of  diarrhea,  dermatitis,  or  intercurrent  disease. 

Injections  may  be  employed  in  about  one-tenth  the  adult  dose.  This 
dose  may  be  doubled  at  the  time  of  second  dentition,  and  trebled  there- 
after. 

Local  Treatment.^The  baby's  skin  must  be  kept  absolutely  clean 
and  dry,  diapers  frequently  changed,  and  powder  freely  used.  Erosions 
and  condylomata  are  to  be  treated,  as  in  the  adult,  by  drying  and  calo- 
mel powder ;  but  it  is  safer  to  dilute  the  calomel  with  two  parts  of 
starch  or  talcum  powder. 

The  nasal  congestion  in  snuffles  may  be  somewhat  reduced  by  anoint- 
ing the  inside  of  the  nose  with  ammoniated  mercury  ointment.  Since 
stomatitis  does  not  occur  in  infancy,  no  especial  care  of  the  mouth  is 
required;  but  erosions  and  fissures  upon  the  lips  may  be  touched  once 
a  week  with  the  nitrate  of  silver  stick. 

It  is  safer,  as  a  general  rule,  not  to  incise  the  furunculoid  lesions, 
inasmuch  as  they  are  discrete  and  are  often  cheesy  rnthor  than  suppu- 
rative ;  Imt  when  at  the  surface  or  already  burst,  they  should  be  cleansed 
daily,  or  twice  a  day,  with  hydrogen  peroxid  diluted  to  one-half  stren'jt.h. 


INDEX 


Abdominal  hydrocele,   604 
Abdominal  retention  of  testicle,  561 
Abnormal  implantation  of  ureter,  536 
Abnormalities.     See  Anomalies 
Abortive  treatment,  of  gonorrhea,  220 

of  syphilis,   824 
Abscess,  of  bladder,  367 

of  Cowper's  glands,  174 

gonorrheal  periurethral,   174 

perinephritic,   336,    337,   343 

periurethral,  264 
treatment  of,  277 

of  prostate,  gonorrheal,  163,  175 
perineal  section  for,  730 
treatment  of,  225 

of  scrotum,  552 

of  testicle,  578 

of  urethral  glands,   162 
treatment   of,   233 
Absence,  of  kidney,  531 

of   penis,   640 

of  testicle,   561 

of   ureter,   536 
Acetate,  of  potassium,  219 

of  zinc,  213 
Acetic  acid  test,  15 
Acquired  syphilis,   796 
Adenitis,  of  chancre,  843 

of   chancroid,   664 

of    gonorrhea,    175 
Adenocarcinoma  of  bladder,  499 
Adenoma  of  prostate.     See  Prostatism 
Albargin,    211 
Albumin,  tests  for,   12 
Alcohol,  in  acute  gonorrhea,  217 

in  chronic  gonorrhea,   223 

in   syphilis,   819 
Alkalies,  in  treatment  of  acute  renal  in- 
fection, ?JiG 

in  treatment  of  acute  urethritis,  218 
Alopecia,  syphilitic,  851 
Alypin,  51 

Ambard  's  constant,  75 
American   scale,   20 
Amputation   of  penis,   787 


Anastomosis  of  ureter,  703 
Anatomy,  of  anterior  urethra,  33 

of   bladder,   710 

of   epididymis,   558 

of  kidneys,  677 

of  penis,  637 

of  perinephritic  fascia,  679 

of  posterior  urethra,  34 

of  prepuce,   639 

of  prostate,  279 

of   scrotum,  549 

of  seminal  vesicle,  616 

of  spermatic  cord,  610 

of  testicle,  557 

of  ureter,  451 

of  urethra,  32 

of  vas  deferens,  610 
Anesthesia,    for   bladder   operations,    712 

for  circumcision,  local,   786 

for  cystoscopy,  51,  52 

for  scrotal  operations,   671 
Aneurysm,  of  renal  artery,  517 

syphilitic,  872 
Angioma,  of  bladder,  500 

of  penis,  653 

of  scrotum,  555 

of  urethra,  509 
Anilin   dyes,   a  cause   of   bladder  tumor, 

365 
Anodynes,  for  gonorrhea,  220 

for  prostatism,  305 
Anomalies,  of  bladder,  538 

of  kidnej ,  530 

of  penis,   639 

of  prepuce,  649 

of  renal  vessels,  533 

of  scrotum,  5*9 

of   seminal  vesicle,   618 

of  testicle,  561 

of  ureter,  536 

of  urethra,  543 

of  vas  deferens,  611 
Anorehism,  561 
Anorectal  gonorrhea,   119 
Anterior  urethra,  anatomy  of,  33 


889 


890 


INDEX 


Anterior  urethra,  bacteria  of,  166 

inflammation  of.     See  Urethritis 

irrigation  of,  25 

urethroscopic  treatment  of,  203 

urethroscopy   of,   201 
Antigonocoecus   serum,  116 
Antisepsis.     See  Asepsis 
Anuria,   calculous,   389 

hysterical,  398 
Aorta,  syphilis  of,  872 
Apparent  absence  of  penis,  640 
Appendicitis    differentiated    from    stone, 

397 
Argentide     emulsion     for     pyelography, 

96 
Argyrol,  211 

for  acute  urethritis,  229 
in  female,   129 

in  pyelography,  93 

for  vaginitis,  143 

for  vulvovaginitis,   134 
Army,  prevalence  of  gonorrhea  in,  101 
Arthritis,   gonorrheal,   122 

syphilitic,   869 
Ascending  renal  infection,  322 
Asepsis,  of  catheterism,  26 

of  cystoscopy,   51 

of   solutions,   30 

of  sounds,  28 

of  syringes  and  tanks,  30 
Aspermia,  627 
Aspiration  of  bladder,  714 
Astringent  urethral  injections,  213 
Atresia,  of   prepuce,   649 

of  urethra,  544 
Atrophy,  of  bladder,  367 

of  kidney,  531 

of  testicle,  588 
Azoospermia,   626 

Bacillus  coli,  319 

of  Ducrey,  660 

tubercle,  424 

typhoid,   350 
Bacteria,  of  chronic  prostatitis,  166 

of  chronic  urethritis,   165 

of  chronic  vesiculitis,  166 

Crabtree  's  method  of  centrifuging  for, 
13 

of  normal  urethra,  166 

of  urinary  infection,  318 
Bacteriuria,    341 
Balanitic  hypospadias,  545 


Balanoposthitis,  645 

gonorrheal,   175 
Ballottement  of  kidney,  3 
Balsamics,  221 
Bar,  prostatic,  289 
Bartholinitis,    151 

Beck's  operation  for  hypospadias,  768 
Belfield  's  operation  for  vasotomy,  245 
Benign  tumors  of  kidney,  485 
Benique  scales,  20 

Bergman's  operation  lor  hydrocele,  780 
Bichlorid     of     mercury,     injections     for 
syphilis,   833 

for  tuberculous  cystitis,  434 
Bigelow's  lithotrite,   753 
Bilateral   incision  of   foreskin,   786 
Bilocular   hydrocele,   604 
Biniodid  of  mercury,  833 
Bladder,  abscess  of,  367 

adenocarcinoma  of,  499 

anatomy  of,  710 

anesthesia  for  operations  upon,  712 

angioma   of,    500 

anomalies  of,  538 

aspiration  of,  714 

atrophy  of,  367 

calculi,   403 

carcinoma   of,   435,   497 

cysts  of,  500 

disease  peculiar  to  the  female,  474 

diverticulum  of,  538 

double,   538 

epithelioma  of,  499 

exstrophy   of,   538 

fibroma  of,  499 

fistula,  operations  for,  763 

foreign  bodies  in,  408 

gangrene   of,   368 

hernia    of,   471 

hypertrophy   of,   356 

inflammation  of.     See  Cystitis 

leukoplakia  of,  371 

myoma  of,  500 

myxoma   of,   500 

naevus  of,  500 

neuroses  in  women,  475 

operations.     See  Cystotomy 

palpation  of,  6 

papilloma  of,  495 

intravesical  cauterization  of,  758 
operative   treatment  of,   720 

paralysis  of,  469 

physiology  of,  465 


INDEX 


891 


Bladder,  puncture  of,  713 

radiography  of,  88 

rupture  of,  521 

sacculated,  538 

sarcoma  of,  500 

stone,   403 

suprapubic  operation  upon,  719 

trabeculated,  538 

tuberculosis,  432 

tumors,  495 

operation  for,  719,  758 

ulcer,  436 

■wounds  of,  520 
Bone,  syphilis  of,  866 

hereditary,    879 
Bottini's  operation,  308,   749 
Bougies,  20 

bulbous,  21 

filiform,  22 

woven,  20 
Brewer's  kidney,  332 
Bromid  of  potassium,  219 
Bronchi,  syphilis  of,  869 
Brou  injection,  214 
Brown-Buerger  cystoscope,  48 
Buccal  gonorrhea,  120 
Buck's  fascia,  637 
Buerger  urethroscope,  200 
Bugbee's  treatment  of  prostatic  carcino- 
ma, 316 
Bulbous  bougie,  21,   197 
Bulbous  urethra,  32 

Cabot's  resection  of  urethra,  734 
Calcification,  of  penis,  655 
of  tunica  vaginalis,  600 
Calculus,  375 

eystoscopic  extraction  of  ureter,  760 
due  to  prostatism,  297 
due  to   stricture,  262 
operation   for   bladder,    719 

for  renal,    688,   692 

for  ureteral,  700 
preputial,    413 

preventive  treatment  of,  379 
radiography,  of  bladder,  88 

of  kidney,  92 

of  prostatic,  87 

of  ureter,  90 
renal,  382 
scrotal,    553 

solvent,  treatment  of,  379 
ureteral,  382 


Calculus,  urethral,  411 

vesical,  403 
Calculous  anuria,  389 

nephrostomy  for,  692 
Calculous  hydronephrosis,  391 
Calculous  prostate,  412 
Carbolic  acid  in  treatment  of  vesical  tu- 
berculosis, 434 
Carcinoma  of  bladder,  435,  497 
eystoscopic  appearance  of,  63 
operative  treatment  of,  720 

of  cervix  invading  bladder,  475 
of  kidney,  489 
of  penis,  656 
of  prostate,  312 

eystoscopic  appearance  of,  62 
urethroscopy    in,    203 
of  seminal  vesicle,   620 
of  testicle,  594 
of  ureter,  454 
of  urethra,  510 
secondary    to    cervical   carcinoma,   475 
secondary  to  renal  calculus,  385 
Castration,   783 

for  prostatism,  308 
Casts  not  found  in  kidney  infection,  342 
Catheter,  23 
asepsis  of,  28 
indwelling,  673- 
irrigation  of  urethra,  207 
life,  307 
retained,   673 
ureter,   50 
Cavernitis,  647 
gonorrheal,   175 
treatment   of,   234 
Cellulitis  of  penis,  647 

of  scrotum,  552 
Cervical  carcinoma  invading  bladder,  475 
Cervicitis,  gonorrheal,   145 
Chancre,  793,  839 
adenitis  of,  843 
diagnosis   of,   822 
extragenital,    796 
treatment  of,  824 
urethral,   188 
Chancroid,  660 
adenitis  of,  664 
lymphangitis   of,   664 
operation  of  preputial  incision  for,  786 
Charriere  scale,  20 
Chemical  cystitis,  364 
Chetwood  irrigation  of  urethra,  206 


892 


INDEX 


Chetwood  operation  for  prostatism,  309, 

746 
Chetwood  tube  for  rectal  irrigation,  210 
Chimney   sweeps'   cancer,  555 
Chordee,  treatment  of,  220,  234 
Chylocele,   609 
Chylous  hydrocele,  554 
Chyluria,   554 
Circumcision,   786 

Circumscribed  fibrosis   of   corpora  caver- 
nosa, 654 
Citrate    of   potassium,    219 
Clinical  urinalysis,  14 
Colic,  renal,   386 

spermatic,  619 
Collargol   in  pyelography,   96 
Colloidal  gold  test,  810 
Colon  bacillus,  319 
Colon,  insufflation  of,  5 

relation  of,  to  kidney,  5 
Complement  fixation  test  for  gonorrhea, 

113 
Compressor  urethrae,  35 
Condyloma,  syphilitic,  854 
Condylomata  acuminata,  653 
Congenital    abnormalities.      See    Anom- 
alies 
Congenital  hydrocele,  603 
Congenital   stricture,   of  ureter,   537 

of  urethra,   251,  544 
Conical  woven  bougies,  20 
Conjunctivitis,   gonorrheal,   127,   129 
Containers,  antisepsis  of,  30 
Contracture  of  bladder  neck,  62 
Contusion,  of  kidney,  511 

of  penis,   642 

of  scrotum,  552 

of  testicle,  588 

of  urethra,  525 
Copaiba,  222 
Corpora  cavernosa,  637 

circumscribed  fibrosis  of,  654 
Corpus  spongiosum,   638 
Costovertebral  tenderness,  3 
Cowper's  glands,  34 

inflammation  of,  174 
Crabtree's  method   of  centrifuging  bac- 
teria, 13 
Crossed  renal  pain,  387 

in  tuberculosis,  421 
Crossed  ureter,  536 
Crusted   syphilid,   851 
Cryoscopy,   75 


Cryptorchidism,  561 

operation  for,  784 
Crypts  of  urethra,  33 
Cubeb,   222 
Curve,  oi  urethra,  38 

of   urethral    instruments,   39 
Cut-off  muscle,  35 

method  of  overcoming  spasm  of,  41 
Cyst,  of  bladder,  500 

of  epididymis,  606 

intravesical  ureteral,  537 

of  kidney,  481 

of  penis,  652 

of  prostate,  311 

of  scrotum,  555 

of  seminal  vesicle,  619 

of  urachus,  543 

of  ureter,  453 

of  urethra,  162,  510 
Cystectomy,  partial,  720 

total,  722 
Cystin  stone,  378 
Cystitis,    364 

cystoscopic  appearance  of,  64 

cystoscopy  in,   59 

due  to   bladder  tumor,  500 

due  to  prostatism,  291,  297 

due  to  urethral  stricture,  262 

gonorrheal,   177 
treatment  of,  235 

in  women,   145 
Cystitis  cystica,  371 
Cystitis  granulosa,  371 
Cystocele,   cystoscopic  appearance  of,  64 

inguinal,   471 
Cystography,   99 
Cystoscope,  47 

sterilization   of,   51 
Cystoscopic  appearance,  of  bladder  stone, 
65 

of  bladder  tumor    63 

of  cystitis,  59 

of  cystitis  cystica,  64 

of  cystocele,  64 

of  diverticulum,  64 

of  normal  bladder,  54 

of  trabeculation  of  bladder,  64 

of  ureter   mouth,   55,   60 

of  ureterovesical  cyst,  64 
Cystoscopic    extraction    of    ureter    stone, 

760 
Cystoscopic  operations,   758 
Cystoscopic  forceps,  760 


INDEX 


893 


Cystoscopy,  53 

anesthesia  for,  51 

of   bladder   tumor,  503 

in  carcinoma  of  the  prostate,  315 

of   carcinomatous  prostate,   62 

contra-indications  to,  59 

in  cystitis,   372 

difficulties  of,  65 

of  enlarged  prostate,  62 

of  female  bladder,  474 

indications  for,  59 

of  inflamed  bladder,  59 

of  inflamed  ureter,  60 

preparation  for,  50 

in  prostatism,  299 

in  pyonephrosis,  346 

in  renal  tuberculosis,  424 

in  tuberculous  cystitis,  60 

of  vesical  calculus,  406 
Cystotomy,   suprapubic,    714,  722 
Cysto-ureteroneostomy,  705 

Dartos,  549 

Decapsulation  of  kidney,  effect  of,  357 

technic  of,  690 
Deferentitis,    568 

treatment  of,  236,  573 
Deformities.     See  Anomalies 
Demulcents,  219 
Dermatitis,   gonorrheal,    121 

mercurial,  832 
Dermoid  cyst,  of  bladder,  500 

of  kidney,  485 
Descending  renal  infection,  321 
Descent  of  testicle,  560 
Diabetic  balanoposthitis,   645 
Diameter  of  urethra,  37 
Diathetic   urethritis,    185 
Dietl's  crisis,  447 
Dilatation,   for  chronic  urethritis,   240 

of  lymphatics  of  penis,  648 

for  stricture  of  urethra,  273 

of  urethra,  543 
Dilator,   Kollmann,  21 
Diminished  excretion  of  solids,  76 
Diphtheria  of  scrotum,  553 
Dislocation,  of  penis,  640,  643 

of  testicle,  588 
Diverticulum,  of  bladder,  538 

eystoscopie   appearance   of,  64 
excision  of,  723 

of  urethra,  543 
Dorsal  slit  of  foreskin,  786 


Double  penis,  639 

Double  ureter,  536 

Double  urethra,  543 

Ducrey   bacillus,    660 

Duration  of   gonorrhea,  103 

Dystrophies  of  hereditary  syphilis,   883 

Dysuria   due   to   kidney   infection,   343 

Ear,  syphilis  of,  862,  881,  886 
Echinococcus  cyst,  of  bladder,  500 

of   kidney,   484 

of   scrotum,   555 

of  seminal  vesicle,   619 

of  spermatic  cord,   105 
Eczema  marginatum  of  scrotum,  550 
Eczema  of  scrotum,  550 
Eczematous  urethritis,   188 
Edema,  of  penis,  647 

of  scrotum,  552 
Ejaculatory  ducts,  35,  611,  617 
Elbowed  catheter,  23 
Elephantiasis,  553 
Embryology  of  testicle,  560 
Embryoma  of  kidney,  487 
Emission,   seminal,  634 
Emphysema   of   scrotum,   553 
Encysted    hydrocele    of    spermatic    cord, 

604 
Endocarditis,    gonorrheal,    125 
English   scale,    20 

Enteroptosis   and   nephroptosis,   443 
Enuresis,   in   children,   466 

postoperative,   468 
in  women,  476 
Epididymeetomy,  783 

indications  for,  587 
Epididymis,  anatomy   of,  558 

cysts  of,  606 

syphilis  of,  592 

tuberculosis  of,  580 
Epididymitis,  566 

due   to   urethral    stricture,   262 

gonorrheal,  567 

non-gonorrheal,  567 

in  prostatism,  297 

relapsing,   570 

due  to  chronic  vesiculitis,  182 
Epididymotomy,    781 
Epididymovasostomy,   782 
Epispadias,   547 

operation    for,    772 
Epithelial  cells,  meaning  of.-  in  urine,  13 
Epithelioma,  of  bladder.  499 


894 


INDEX 


Epithelioma,  of  kidney  pelvis,  493 

of  penis,  656 

of  scrotum,  555 

of  ureter,  454,  493 
Erysipelas,  of  penis,  647 

of  scrotum,  552 
Erythema,   gonorrheal,   121 
Essential  kidney  hematuria,  478 
Estimation   of  kidney  function,   75 
Evaeuators  for  litholapaxy,  753 
Eversion   of  hydrocele,   780 
Examination,  physical,  1 
Excision  of  diverticulum,  723 
Exostosis,  gonorrheal,  125 
Experimental   oliguria,   76 
Experimental   polyuria,    76,   83 
Experimental   syphilis,   805 
Exstrophy   of   bladder,   538 

operation   for,    773 
External  urethrotomy.     See  Perineal  sec- 
tion 
External   urinary   tract,    34 
Extirpation  of  penis,   789 
Extragenital  chancre,  796 
Extragenital   syphilitic   infection,   795 
Extra-urethral  perineal  prostatectomy,  739 
Eye,  gonorrhea  of,  127 

hereditary   syphilis   of,   881,    886 

syphilis  of,  866 

False  passage,  urethral,  262 

treatment  of,  277 
Female  bladder,  cystoscopy  of,  474 
Female  urethra,  gonorrhea  of,  141 

prolapse  of,  545 
Fetal  syphilis,  874 
Fibrolipomatous   perinephritis,    335 
Fibroma,  of  bladder,  500 

of  kidney,  485 

of  scrotum,  555 

of  urethra,  509 

of  vas  deferens,  614 
Fibromyoma  of  prostate,  283 
Fibrosis  of  the  corpora  cavernosa,  654 
Filiform  bougie,  22 

indwelling,   674 

introduction   of,    274 
First  and  second  urines,   comparison  of, 

17 
Fistula,  of  bladder,  472 

complicating    stricture,    treatment    of, 
278 

of  kidney,  operation  for,  761 


Fistula,   operation  for  penile,  765 

for  perineal,  765 
for  ureteral,  763 
for  urethrorectal,  764 
for  urinary,  761 
for  vesical,  763 
for  vesico-intestinal,  763 
for  vesico-uterine,  764 
for  vesicovaginal,  763 
perineal,  265 
rectal,   528 
of  scrotum,  553 
of  urachus,  543 
of  ureter,  454 

of  urethra,  penile,  174,  233 
Floating  kidney,  441 
Focal  suppurative  nephritis,  332 
symptoms  of  340 
treatment   of,   356 
Forceps,  cystoscopic,   760 
Foreign  bodies,  in  bladder,  408 

in  urethra,  410 
Foreskin.     See  Prepuce 
Fracture,   of  penis,   642 

of   stone,   spontaneous,   404 
Freezing  point,  estimation  of,  75 
French   scale,   20 

Fulguration  of  bladder  tumor,  503 
Function,   estimation  of  kidney,    75 
Functional   impotence,   623 
Fusion   of   kidneys,   531,   534 

Galvanocauterization  of  the  prostate,  746 
Gangrene,  of  bladder,  368 

of  chancre,  843 

of  chancroid,  664 

of  penis,  648 

periurethral,  265 

of  scrotum,  552 

of  testicle,  589 
General  physical  examination,  2 
Genital  function,  maladies  involving  the, 

621 
Genito-urinary  tuberculosis,   414 

See  also  Tuberculosis 
Giemsa   stain,   803 
Glands  of  urethra,  33 
Glans  penis,  637 
Gleet,  260 

Globulin  reaction,  809 
Glossitis,  syphilitic,  860 
Goldschmidt  urethroscope,  200 
Golf-hole  ureter,  61 


INDEX 


895 


Gonocoecus,  107 
culture  of,  110 

complement  fixation  test  for,  113 
diagnosis  of,   111 

in  chronic  urethritis,  192 
Gram-negative,   109 
immunity   to,  117 
pathological   extension   of,   118 
Gonocoecus  vaccines,   114 
Gonorrhea,  100 

and  marriage,   155 
ano-rectal,   119 
buccal,  120 

curability  of,  103,  154,  192 
duration  of,  103 
of   female   urethra,   141 
gravity  of,   103 

instructions  to  patients  having,  222 
of  male  urethra,  157 
course  of,   168 
incubation   of,   169 
symptoms  of,  168 
treatment  of,  local,  225 
systemic,  216 
nasal,   120 
ocular,  127 
prevalence  of,   101 
prognosis  of,  in  man,   103,  192 

in  woman,  152,  155 
prophylaxis  of,  106 
in   man,   225 
in  woman,   155 
rectal,  119 

social  aspects  of,  100 
social  remedies  for,  106 
sterility  from,  105 
systemic,   121 
transmission  of,  118 
female,  143 
male,  216 
treatment   of,   social,    106 
in  women,  137 
Gonorrheal  adenitis,  175 
Gonorrheal  arthritis,   122 
Gonorrheal  balanoposthitis,  175 
Gonorrheal  cavernitis,  175 
Gonorrheal  cervicitis,  145 
Gonorrheal  conjunctivitis,  127 

systemic,  129 
Gonorrheal  cystitis,   171 

treatment   of,   235 
Gonorrheal  endocarditis,  125 
Gonorrheal  epididymitis,  567 


Gonorrheal    epididymitis,    operation    for, 

781 
Gonorrheal  erythema,  121 
Gonorrheal  exostosis,  125 
Gonorrheal   iritis,   127,   129 
Gonorrheal  kidney  infection,  350 
Gonorrheal  lymphadenitis,  175 
Gonorrheal  lymphangitis,   175 
Gonorrheal  neurosis,  121 
Gonorrheal  peritonitis,   177 
Gonorrheal  periurethritis,  174 
Gonorrheal    prostatic    abscess,    175 
Gonorrheal   prostatitis,    163,   175 
symptoms  of,  169,  179 
treatment  of,  235 
Gonorrheal  pruritis,   121 
Gonorrheal  retinitis,  130 
Gonorrheal  rheumatism,    122 
due  to  vesiculitis,  182 
frequency  of,  105 
Gonorrheal  seminal   vesiculitis,    165,    175 
Gonorrheal  spongeitis,   175 
Gonorrheal   urethritis,    diagnosis   of,    191 
in  female,  142 
in   male,   157 

acute,  complications  of,  174 
expectant  treatment  of,  232 
local  treatment  of,  225 
pathology  of,  159,  162 
preventive  treatment  of,  225 
repressive  treatment  of,  227 
symptoms   of,   169 
systemic  treatment  of,  216 
terminal   treatment  of,   232 
treatment  of,  216     " 
chronic,   course   of,   178 
local  treatment  of,  238 
pathology  of,   160,  162 
symptoms  of,  179  . 
treatment  of,   223 
Gonorrheal  vaginitis,    148 
Gonorrheal  vesiculitis,   symptoms  of,   182 
Gonorrheal  vulvitis,   150 
Gonorrheal  vulvovaginitis,   131 
Gouty  urethritis,  185 
Gram  reaction,  109 
Gray   oil,   833 
Gubernaculum  testis,  560 
Gumma,   860 
of  bone,  866 
of  nasal  septum,  852 
of  palate,  861 
pathology  of,  812 


896 


INDEX 


Gumma,  of  penis,  652 

of   tongue,   861 
Gunshot  wounds,  of  bladder,  820 

of  kidney,  517 
Guyon  instillator,  25 
Guyon  obturator,  24 

Habenula,  560 

Heart,  syphilis  of,  872 

Hematocele,    608 

of  cord,  605 

scrotal,  552 
Hematogenous  renal  infection,  321 
Hematuria  due  to  aneurysm  of  renal  ar- 
tery, 517 

due  to  bladder  stone,  406 

due  to  bladder  tuberculosis,  433 

due  to  bladder  tumor,   500 

due  to  cystitis,  369 

due  to  cystitis  cystica,  371 

due  to  gonorrheal  urethritis,  172 

due  to  hydronephrosis,    461 

due  to  nephroptosis,    447 

due  to  prostatic   calculus,   413 

due  to  prostatic   carcinoma,   314 

due  to  prostatism,   294 

due  to  pyelitis  cystica,  337 

due  to  renal   stone,   387 

due  to  renal   tuberculosis,   421 

due  to  renal  tumor,  489 

due  to  rupture  of  kidney,  513 

due  to  urethral    stricture,    261 

idiopathic,   478 
Hemorrhoids  due  to  urethral  stricture,  261 
Hereditary  syphilis.     See  Syphilis,  hered- 
itary 
Hermaphroditism,  641 
Hernia  of  bladder,  471 
Hernial  sac,  hydrocele  of,  605 
Herpes  progenitalis,   644 
Herpetic  urethritis,  188 
Hexamethylenamin   for  acute   gonorrheal 
urethritis,   218 

preceding  instrumentation,  28 

preceding   operation,   671 

for    pyelonephritis,    359 
Hiccough  due  to  urinary  toxemia,  344 
High  frequency  cauterization,  of  bladder 
lesions,  503,  758 

of  prostatic  carcinoma,   316 

of  urethral  lesions,  204 
Horn  of  penis,  654 
Horsesh'iA  kidney,   534 


Hunterian  chancre,  841 
Hutchinson's  teeth,   885 
Hydatid  of  Morgagni,  557 
Hydrocele,  598 

abdominal,  604 

bilocular,  604 

chylous,  554 

congenital,   603 

encysted,  of  spermatic  cord,  604 

of  hernial  sac,  605 

idiopathic,   598 

infantile,  604 

inguinal,  605 

light  test  for,  602 

multilocular,  601 

operations  for,  778 

of  spermatic  cord,  604,  605 

symptomatic,   598 

syphilitic,  593 

tuberculous,  583 
Hydronephrosis,    456 

calculous,   391 

nephrostomy  for,  692 

traumatic,  515 
Hygiene,  of  gonorrhea,  217,  223 

of  prostatism,  304 

of  syphilis,  837 
Hypernephroma,  486,  488 
Hypertrophy,  of  bladder,  367 

of  prostate.     See  Prostatism 
Hypospadias,  545 

operation  for,  768 

Idiopathic   hydrocele,   598 
Idiopathic   renal   hematuria,  478 
Immunity,  to  gonococcus,  117 

to  syphilis,  806 
Impotence,  621 

after  prostatectomy,  310 

functional,  623 
Incision,  lumbar,  682,  684 
Incontinence  of  urine.     See  Enuresis 
Incrustation,  of  bladder  ulcer,  436 

of  kidney  pelvis,  338 
Incubation,  of  gonorrhea,  169 

of  syphilis,  815 
Incurvation   of  penis,  654 
Indigocarmin,  renal  function  test,  78 
Indwelling  catheter,  24,  673 
Indwelling  filiform,   674 
Indwelling   ureter   catheter   in   treatment 
of   pyelonephritis  in  pregnancy, 
361 


INDEX 


897 


Indwelling  ureter  catheter  in  treatment 

of  urinary  septicemia,  362 
Infancy,  renal  infection  in,  348 
Infantile    hydrocele,    604 
Infantile  syphilis,  876 
Infarcts  of  kidney,  septic,  332 
Infiltration  of  urine,  265 
Inguinal  adenitis,  of  chancre,  843 

of   chancroid,   664 

of   gonorrhea,    175 
Injection,  of  hydrocele,  779 

mercurial,   833 

salvarsan,  826 

of  urethra,  205 

in   chronic   urethritis,   239 
solutions   for,   210 
Instillation  of  urethra,  207 
Instillations,  for  chronic  urethritis,  239 

for   bladder   tuberculosis,   434 

for  vulvovaginitis,  135 
Instillators,   25 

Instructions    to    patients    having    gonor- 
rhea, 222 
Instruments,  urethral.     See  Urethral  in- 
struments 
Insufficiency,   renal.      See   Kidney   insuf- 
ficiency 
Insufflation  of  the  colon,  5 
Intermittent  hydronephrosis,  460 
Internal  secretion  of  testicle,  559 
Internal  urethrotomy,   730 
Internal  urinary  tract,  34 
Interstitial  cystitis,  371 
Intertrigo   of   scrotum,  550 
Intestinal  syphilis,   871 
Intestine,  anastomosis  of  ureter  with,  707 
Intramuscular  injections  of  mercury,  833 
Intra-urethral  perineal  prostatectomy,  743 
Intravesical  cystoscopic  operations,   758 
Intravesical  ureteral   cyst,  537 
Inunction  with  mercury,   836 
Iodoform  for  vesical  tuberculosis,  434 
Iritis,   gonorrheal,    127,    129 

syphilitic,  866 
Irrigation,  rectal,  209 
of  urethra,  205 

in  chronic  urethritis,  239 

urethral,   25 
Irritable  testicle,  590 

Janet  syringe,  25 
Joints,  gonorrhea  of,  122 
sypliilis  of,  869 


Kava-kava,   222 
Keyes  instillator,  25 
Kidney,  anatomy  of,  677 
anomalies  of,  530 
artery,  aneurysm  of,  517 
atrophy  of,  531 
ballottenient  of,   3 
benign  tumors  of,  485 
calculus,  382 

and   carcinoma,   385 

radiography  of,  92 
carcinoma   of,   489 
colic,   386 

differential  diagnosis  of,  397 

due  to  vesiculitis,  182 

symptoms  of,   388 

treatment  of,  398 
congenital   atrophy   of,  531 
contusion   of,  511 
cystic  degeneration  of,  482 
cysts  of,  481 
decapsulation  of,  690 
dermoid  cysts  of,  485 
echinococcus  cysts  of,  484 
embryoma  of,  487 
fistula,  operations  for,  761 
floating,   441 

function,  estimation  of,  75 
function  test,  75 

Ambard's  constant,  75 

blood  nitrogen,  76 

experimental   polyuria,   83 

indigocarmin,    78 

phenolsulphonephthalein,  78 

urea,  76 

with  ureter  catheter,   85 
fusion  of,  531,  534 
gunshot  wounds  of,  517 
hematuria.     See  Hematuria 
horseshoe,  534 
hypernephroma  of,  486,  488 
incision,  for  operation  upon,  682 

transperitoneal,  686 
infection,   318 

due  to  calculus,  392 

due  to  prostatism,  291 

due  to  urethral  stricture,  262 

etiology  of,  318 

gonorrheal,  350 

in  infancy,  348 

pathology  of,  331 

postoperative,  350 

in   pregnancy,  349 


898 


INDEX 


Kidney  infection,  in  prostatism,  297 

typhoid,   350 
malformations  of,  530 
malignant  tumors  of,  485 
misplaced,   533 
movable,   441 
neoplasms  of,  485 

operations.  See  Nephrectomy,  Nephrot- 
omy 
operation  upon,  preparation  for,  682 
palpation  of,  3 

pelvis,  inflammation  of.     See  Pyelone- 
phritis 

relation  of  vessels  to,  681 

resection  of,  703 

tumors   of,   493 
polycystic,  482 
rupture  of,  511 
sarcoma  of,  489 
single,  531,  534 
stone,  382 
supernumerary,   535 
suture  of,  689 
tuberculosis,  416 

cystoscopy  in,  424 

hematuria  in,  421 

nephrectomy  for,  696 
vessels,  anomalies  of,  533 
wounds  of,  516 
Kollmann  dilator,  21 

Lack  of  flexibility,  a  renal  function  test, 

83 
Lacuna  magna,  33 
Late  hereditary  syphilis,   883 
Laus  veneris,  551 

Lavage  of  the  renal  pelvis,  360,  362 
Length   of  urethra,   37 
Leukoplakia,  of  bladder,  371 

of  kidney  pelvis,  338 

syphilitic,    854 
Lichen   planus,   644 
Light  test  for  hydrocele,  602 
Liquor   potassse,   219 
Litholapaxy,  752 
Lithotomy,   719 
Lithotrites,   752 
Liver,  syphilis  of,  870 

hereditary,  881 
Local    anesthesia,    for    circumcision,    786 

for  cystoscopy,   51 

for  perineal   section,   727 

for  scrotal  operations,  775 


Local    anesthesia,    for    suprapubic    pros 

tatectomy,  736 
Lubrication  of  urethral  instruments,  29 
Luetin  test,  808 
Lumbar  incisions,  682,  684 
Lung,  syphilis  of,  869 

hereditary,   881 
Luxation  of  testicle,  588 
Lymph  scrotum,  553 
Lymph  varix,  553 
Lymphadenitis,  of  chancre,  843 

of  chancroid,  664 

gonorrheal,  175 
Lymphangitis  of  penis,  647 
Lymphocytosis   of   cerebrospinal  fluid  in 
syphilis,  809 

Macular  syphilid,  849 
Malakoplakia  of  kidney  pelvis,  337 
Malformations.     See  Anomalies 
Marriage,   and   gonorrhea,   155 

and  syphilis,  797 
Massage  of  prostate  and  seminal  vesicles, 

240 
Maydl's  operation,   709 
Mayo  operation  for  hypospadias,  769 
Meatotomy,   767 
Meatus  urinarius,  32 

stricture  of,  251 
Median  perineal  section,  725 
Membranous  cystitis,  368 
Membranous  urethra,  34 

palpation  of,  8 
Mercurial  dermatitis,  832 
Mercurial  nephritis,  832 
Mercurial  stomatitis,  831 
Mercury,  in  treatment  of  syphilis,  829 

intramuscular  injections   of,   833 

inunction  with,  836 

salivation  by,  831 

toxicology  of,  830 
Metal  instruments,  technic  of  passage  of, 

42 
Micrococcus   catarrhalis,    112 
Middle   lobe  of  prostate,  289 
Misplaced   kidney,   533 

Nails,  hereditary  syphilis  of,  878 
Nasal  gonorrhea,  120 
Nasal  septum,  syphilis  of,  862 
Natural   curve  catheter,   24 
Neoplasm.     See  Tumors 
Nephrectomy,  694 


INDEX 


899 


Nephrectomy,    for    kidney    tuberculosis, 
696 

for  large  kidney,  697 

for  neoplasm,  698 

preparation   for,   682 

subcapsular,  696 
Nephritis,  nephrotomy  for,   692 

tuberculous,  420 

See  also  Kidney  infection 
Nephropexy,  449,   690 
Nephroptosis,  441 
Nephrostomy,  691 

for   calculous   anuria,   692 

to  divert  the  urinary  stream,  705 

for  hydronephrosis,  692 

preliminary,  694 

for  pyonephrosis,  692 

for  tuberculosis,  692 
Nephrotomy,   688 

for  nephritis,  692 

preparation   for,   682 
Nervous  system,  syphilis  of,  863 

hereditary,   881 
Neuralgia  of  testicle,  590 
Neurasthenia,  sexual,  624 

due   to   urethral   stricture,   261 
Neurorecidiv  of  syphilis,  828 
Neurosis,  gonorrheal,  181 

of  bladder,  in  woman,  475 
treatment   of  urethral,  246 
Nitrate  of  silver,  213 
Nitrogen  estimation  of  blood  and  urine, 

75 
Nonbacterial  cystitis,  364 
Nongonorrheal  urethritis,   185 
Normal   bladder,   cystoscopic   appearance 

of,  54 
Normal  urethra,  bacteria  of,  166 
Nose,  hereditary  syphilis  of,  876 
Nov6-Josserand    operation    for    hypospa- 
dias, 770 

Oberlaender,  urethritis  of,   160 

Oblique   lumbar  incision,   684 

Ocular   gonorrhea,    127 

Ocular  syphilis.     See  Syphilis  of  the  eye 

hereditary,  881,   886 
Ointments    for    treatment   of   gonorrheal 

urethritis,   215 
Olivary  catheters,  23 
Onset  of  syphilis,  814 
Operating    cystoscope,    758 
Operation,  upon  bladder.     See  Cystotomy 


Operation,  for  cryptorchidism,  784 

for  epispadias,   772 

for  hydrocele,  778 

for  hypospadias,   768 

upon   kidney.      See    Nephrectomy,    Ne- 
phrotomy 

upon  penis,  786 

preparation  for,  669 

for  retained  testis,  784 

for  ruptured  urethra,  768 

upon  scrotum,  775 

upon   seminal  vesicles,   245,   751 

for   spermatocele,   781 

upon   ureter,   700 

upon  urethra,  725,  764 

for  urinary  fistula,  761 

upon  urinary  organs,  668 

for  varicocele,  777 

for  vesicovaginal  fistula,  763 
Orchidectomy,  783 
Orchitis,    577 
Organic   silver  salts,   211 
Organic  urethral  stricture,  253 
Ossification  of  penis,  655 
Oxalate  stone,  377 
Oxycyanid  of  mercury,  213 

Painful  urination,   treatment  of,  220 
Palate,  syphilis  of,  861 
Palpation,  of  bladder,  6 

of  kidney,  3 

of  membranous  urethra,  8 

of   penis,   9 

of  perineum,  8 

of  prostate,  7 

of  seminal  vesicles,  7 

of  testicle,  9 

of  ureter,  5 

of  urethra,  9 

of  vas  deferens,  10 
Pampiniform  plexus,  610 
Papilloma,  of  bladder,  495 

cystoscopic  appearance  of,  63 
fulguration  of,  758 

of  penis,  653 

of  renal  pelvis,  493 

of  ureter,  454,  493 

of  urethra,  162,  187,  509 
Papular  syphilid,  850 
Paralysis  of  bladder,  469 
Paranephritic  cysts,  481 
Paraphimosis,  650 
Parasyphilids,   794 


900 


INDEX 


Paraurethral     canal,     treatment     of     in- 
flamed, 234 
Parenchymatous  keratitis,  886 
Partial  cystectomy,   720 
Passage,  of  soft  urethral  instruments,  41 

of  sounds,  42 
Pediculi  pubis,   551 
Pelvic  lavage,  360,  362 
Pemphigus,  syphilitic,  878 
Penis,  absence  of,  640 

amputatioji  of,  787 

anatomy  of,  637 

anomalies  of,   639 

apparent  absence  of,  640 

calcification  of,  655 

cellulitis   of,    647 

circumscribed  fibrosis  of,  654 

condyloma  of,  653 

contusions  of,  642 

cysts  of,  652 

dilatation  of  lymphatics  of,  648 

dislocation  of,  640,  643 

double,  639 

edema   of,   647 

epithelioma  of,  656 

erysipelas  of,  647 

extirpation   of,   789 

fistula  of.     See  Fistula 

fracture  of,  642 

gangrene  of,  648 

gumma  of,  652 

horns  of,   654 

incurvation   of,  654 

infiammation    of,   647 

lichen  planus  of,  644 

lymphangitis  of,   647 

neoplasms  of,   652 

operations  upon,   786 

ossification  of,  655 

palpation  of,  9 

papilloma  of,  653 

sarcoma  of,  656 

scabies  of,  644 

torsion  of,   640 

tuberculosis   of,   648 

tumors  of,  652,  656 

wounds  of,  641 
Percussion  of  bladder,  6 
Pericystitis,   367,   371 
Perineal   fistula,   operation   for,   765 
Perineal  prostatectomy,  739 

results  of,  468 
Perineal  section,  725 


Perineal  section,  with  guide,  730 

without  guide,   732 

under  local  anesthesia,  727 

passage  of  sounds  after,  732 

for  periurethritis,  734 

for  prostatic  abscess,  730 

for  ruptured  urethra,  733,  758 

for   stricture,   269,   273,    725 
Perinephritie  abscess,  336,  347,  357,  363 
Perinephritic   fascia,  anatomy   of,   679 
Perinephritis,   fibrolipomatous,   335 

in  infancy,  348 

suppurative,   336,  347,  363 
Perineum,  palpation  of,  8 
Peritonitis,   gonorrheal,    177 
Periurethral  abscess,  264 

operation  for,  734 
Periurethral  gangrene,  265 
Periurethral   phlegmon,   265 
Periurethritis,   due   to   stricture,  264 
treatment  of,  277 

gonorrheal,   174 
treatment   of,    233 

operative  treatment  of,  734 
Permanganate  of  potassium,  212 

irrigation  with,  231 
Permanganate  of  silver,  213 
Peters 's   operation,   709 
Phagedenic  chancre,  843 
Phagedenic  chancroid,  664 
Phagedenic  gumma,  664,  843 
Phenolsulphonephthalein,   intravenous  in- 
jection of,  82 

in  operative  preparation,  671 

in  prostatism,  300 

with  the  ureter  catheter,  82 
Phimosis,  649 
Phlebolith,  92 

Phlegmon,  periurethral,  265 
Phlorizin,  76 
Phosphatic  stone,  378 

radiography  of,  87 
Physical   examination,   1 
Physiology,  of  bladder,  465 

of  cut-off  muscle,  40 

01  iddney,  75 

oi"  prostate,  281 

Oi.  seminal  vesicle,  617 

of  testicle,  C59 

01   ureter,  452 

of  urethra,  39 
Pilimiction,  409 
Pityriasis  of  scrotum,  550 


INDEX 


901 


Plantar   syphilids,    853 

Pleura,  injury  to,  iu  nephrectomy,  686 

Pneumaturia,  472 

Pneumonia,    syphilitic,    870 

Pollution,  634 

Polycystic  kidney,  482 

Polyorchism,   561 

Polyuria,   experimental,   76,   83 

Posterior  urethra,  anatomy  of,  34 

urethoscopy  of,  202 
Posterior  urethritis.     See  Urethritis 
Postgonorrheal  neurosis,  181 
Postoperative  renal  infection,  350 
Posture  in  the  treatment  of  renal  infec- 
tion, 355 
Potassium  acetate,  219 
Potassium  bromid,  219 
Potassium  citrate,  219 
Potassium   hydrate,   219 
Potassium  iodid,  837 
Potassium  permanganate,  212 
Potassium   permanganate   irrigation,   231 
Pregnancy,  renal  infection  in,  349 

treatment  of,  361 
Preliminary  cystotomy,   670,   714 
Preliminary    nephrostomy,    694 
Preparation,  for  catheterism,  41 

for  cystoscopy,  50 

for  operation,   669 
upon  kidney,  682 
Prepuce,   anatomy  of,  639 

anomalies  of,  649 

calculus  of,  413 

incision  of,  for  chancroid,  786 

inflammation  of,   645 
Prevalence  of  gonorrhea,  101 
Prevention,   of  gonorrhea,   106,   155,   225 

of   syphilis,   823 
Priapism,    635 

Prolapse  of  female  urethra,  545 
Prophylaxis.      See    Prevention 
Prostate,  anatomy  of,  279 

cysts  of,  311 

hypertrophy  of.     See  Prostatism 

inflammation  of.     See  Prostatitis 

palpation  of,  7 

physiology   of,   281 

tuberculosis   of,   436 
Prostatectomy,     incontinence     of     urine 
after,  468 

intra-urethral,  perineal,  742 

for  neoplasm,  749 

perineal,  extra -urethral,  739 


Prostatectomy,  results  of,  309,  468 

suprapubic,  736 
Prostatic  abscess,  gonorrheal,   175 

perineal  section  lor,  730 

treatment  of,  235 
Prostatic  bar,  cystoscopic  appearance  of, 

62 
Prostatic  calculus,  412 
Prostatic  carcinoma,  312 
Prostatic  catheters,  25 
Prostatic   hygiene,   304 
Prostatic  hypertrophy.     See  Prostatism 
Prostatic  massage,  240 

technic  of,  242 
Prostatic  neoplasm,  311 

operation  for,  749 
Prostatic  sarcoma,  311 
Prostatic  stone,  412 
Prostatic  urethra,  35 
Prostatism,    282 

cystoscopic  appearance  of,  62 

operations   for,   735 

preparation  for  operation  for,  670 

urethroscopy  in,  203 
Prostatitis,  bacteria  of  chronic,  166 

due  to  urethral  stricture,  262 
treatment  of,  276 

gonorrheal,   163 
symptoms  of,  179 
treatment  of,  235 
Prostatorrhea,    181,    189 
Prostatotomy,   by   Bottini's  method,   749 

by  Chetwood  's  method,  746 

by   Young's  punch,  748 
Protargol,   211 

in  acute  urethritis,  228 
Provoked    Wassermann    reaction,   808 
Pruritis,   gonorrheal,   121 
Pubis,   pediculi   of,  551 
Puncture  of  bladder,  713 
Pustular  syphilid,  851 
Pyelitis.     See  Pyelonephritis 
Pyelitis  cystica,  337 
Pyelitis  granulosa,  337 
Pyelography,  93 

dangers    of,    97 

for  renal  and  ureteral  calculus,  396 

for    renal    tuberculosis,    427 

technic   of,   99 
Pyelonephritis,   due  to  calculus,   392 

due  to  urethral  stricture,  262 

etiology  of,  318 

pathology  of,  334 


902 


INDEX 


Pyelonephritis,  symptoms  of,  341 

treatment  of,  355 
Pyeloplieation,  703 
Pyelotomy,  690 
Pyemic  kidney,  332 
Pyonephrosis,  calculous,  392 

cystoscopy  in,  346 

nephrectomy    for,    697 

nephrostomy  for,  692 

pathology  of,  334 

symptoms  of,  346 

treatment  of,  363 

Kachitis  and  hereditary  syphilis,  882 
Radiographic   ureter   catheter,   93 
Eadiography,  87 

of  bladder  calculi,  88 

of  kidney  calculi,  92,  392,  394 

of  prostatic  calculi,  87 

in  renal  tuberculosis,  427 

injection.     See  Cystography,  Pyelog- 
raphy 

of  ureter  calculi,  90,  392,  394 
Eeaction,   Wassermann,   806 
Rectal  douche,  244 
Eectal  gonorrhea,   119 
Rectal  irrigation,  209 
Rectal  palpation,  of  bladder,  7,  9 

of  prostate,  7 

of  seminal  vesicles,  7 

of  ureters,  6 
Relapsing   epididymitis,   570 

due  to  chronic  vesiculitis,  182 
Eenal.     See  Kidney 
Renorenal   reflex,  387 

in  tuberculosis,  421 
Repressive  treatment  of  gonorrheal  ure- 
thritis, 227 
Eesection,  of  bladder,  720 

of  kidney  pelvis,  703 

of  urethra,   734 
Eetained   catheter,   673 
Eetained  testis,  561 

operation   for,   784 
Retention  of  urine,  a  cause  of  calculus, 
380 

a  cause  of  renal  infection,  326,-  349 

due  to  bladder  calculi,  .406 

due  to  bladder  tuberculosis,  433 

due  to  carcinoma  of  the  prostate,  314 

due  to  prostatism,   290 

due  to  renal  infection,,  349 

due  to  stricture  of  the  urethra,  261 


Retention  of  urine,  effect  of,  upon  blad- 
der, 292 

in  women,  476 
Retinitis,  gonorrheal,  130 
Rheumatism,  due  to  urinary  toxemia,  344 

gonorrheal,   due   to   vesiculitis,    182 
Rickets  and  hereditary  syphilis,  882 
Rochet  operation  for  hypospadias,  771 
Rubber  catheters,  23 
Rupture,  of  bladder,  521 

of  kidney,  511 

of  ureter,  518 

of  urethra,  525 

operation  for,  733,  768 

Sacculated  bladder,"  538 
Salivation   by  mercury,  831 
Salvarsan,    826 

and  infectiousness  of  syphilis,  799 
Sandalwood  oil,  221 
Sarcoma,  of  bladder,  500 

of  kidney,  489 

of  penis,  656 

of  prostate,  311 

of  urethra,  510 
Scabies,  644 

Scales  for  urethral  instruments,  20 
Sciatica   due   to    carcinoma   of   prostate, 

314 
Scrotum,    abscess   of,   552 

anatomy   of,   549 

anomalies  of,  549 

calculus  of,  553 

cellulitis  of,  552 

contusion   of,  551 

cysts  of,  555 

diphtheria  of,  553 

diseases  of,  549 

eczema   of,  550 

eczema  marginatum  of,  550 

edema  of,  552 

elephantiasis   of,   553 

emphysema  of,  553 

epithelioma  of,  555 

erysipelas  of,  552 

fistula  of,  553 

gangrene  of,  552 

hematocele  of,  552 

inflammations  of,  552 

intertrigo  of,  550 

lymph,  553 

operations  upon,   775 

pityriasis  of,  550 


INDEX 


903 


Scrotum,  tumors  of,  555 

wounds  of,  551 
Second  attack  of  syphilis,  800 
Secondary  lesions  of  syphilis,  793,  816 
Secondary  syphilis,  of  mucous  membrane, 
853 

of  skin,  848 

treatment  of,  825 
Self-abuse,    629 
Seminal  emissions,  634 
Seminal  vesicle,  anatomy  of,  616 

anomalies  of,   618 

calculi  of,  619 

cysts  of,  619 

inflammation  of.     See  Seminal  vesicu- 
litis 

palpation  of,  7 

physiology  of,  617 

tuberculosis  of,  438 

tumors  of,  620 

wounds  of,  619 
Seminal  vesiculectomy,  751 
Seminal  vesiculitis,  due  to  urethral  stric- 
ture, 262 

gonorrheal,  165,  175 

operations  for,  244,  751 

symptonis  of,  182 

treatment   of,   236 
Seminal   vesiculotomy,    751 
Sensibility  of  urethra,  39 
Septicemia,  urinary,  345 
Serum,  antigonococcus,   116 
Sexual  hygiene,  in  acute  gonorrhea,  217 

in  chronic  gonorrhea,  224 
Sexual  neurasthenia,  624 

due  to  urethral  stricture,  261 

treatment  of,  246,  625 
Shock,  urethral,  40 
Shreds  in  urine,  198 
Silver  catheter,  25 
Silver  nitrate,  213 
Silver  permanganate,  213 
Silver  salts,  organic,  211 
Simple  ulcer  of  bladder,  435 
Simple  urethritis,   185 
Sinclair's  method   of    tying   catheter   in 

urethra,  675 
Single   kidney,  530 
Sinus  pocularis,  35 
Skin,   syphilis  of,  846 

hereditary,  877 
Smegma  bacillus,  424 
Social  aspects  of  gonorrhea,  100 


Sodium  bicarbonate,  219 
Solids,  diminished  excretion  of,  76 
Soluble  injections  of  mercury,  833 
Solutions,  antisepsis  of,  31 

for  injection  of  urethra,  210 
Sounds,  20 

introduction  of,  42 

after   urethrotomy,   732 

in  treatment  of  stricture,  269,  271 
Spasmodic  stricture,  249 

method  of  overcoming,  41 
Spermatic  cord,  610 

encysted  hydrocele  of,  604 

hematocele  of,  605 

multilocular  hydrocele  of,  605 

torsion   of,  589 

tumors  of,  614 

wounds  of,  590 
Spermatocele,  606 

operation  for,  781 
Spermatorrhea,    181,   189 
Sphincter,  urethral,  36 
Spinal  fluid  tests  for  syphilis,  809 
Spiroehaeta    pallida,    803 
Spleen,  hereditary   syphilis  of,  881 
Spongeitis,   175 

treatment  of,  234 
Spontaneous  fracture  of  calculi,  404 
Squamous  syphilid,  852 
Sterility,  626 

from   gonorrhea,   105 

operation  for,   782 
Sterilization.      See   Asepsis 
Stigmata  of  hereditary   syphilis,   884 
Stomach,  syphilis  of,  871 
Stomatitis,  mercurial,  831 
Stone.     See   Calculus 
Streptobacillus  of  Ducrey,  660 
Stricture,  of  meatus,  251 

of  neck  of  bladder,  62 

of  ureter,  453 

of  urethra,  congenital,   251,  544 
organic,  253 

retention  of  urine,   due   to,   261 
spasmodic,  249 
traumatic,   254,  276 
Subcapsular   nephrectomy,   696 
Subcutaneous  ligation  of  varicocele,  777 
Sulphate  of  zinc,  213 
Supernumerary  kidney,  535 
Suppurative   nephritis,   332 
Suppurative  jjerinephritis,  336 
Suprapubic   aspiration,   714 


904 


INDEX 


Suprapubic  cystostomy,  722 
Suprapubic  cystotomy,  714 

for   diverticulum,   723 

for    stone,    719 

for  tumor,   720 
Suprapubic   lithotomy,    719 
Suprapubic     prostatectomy.       See    Pros- 
tatectomy 
Sweet  spirits  of  niter,  219 
Swinburne  urethroscope,  201 
Symptomatic  hydrocele,  598 
Synorchism,  561 
Syphilid,    crusted,   851 

hereditary,   877 

macular,  849 

of   mucous  membranes,   853,   862 

palmar,   853 

papular,  850 

pigmentary,  853 

plantar,   853 

pustular,  851 

secondary,  848 

serpiginous,  858 

squamous,  853 

tertiary,  856 

tubercular,  856 

ulcerated,   857 
Syphilis,  793 

acquired,   793 

and  marriage,  797 

of  aorta,  872 

of  articulation,  869 

of  bones,  866,  879 

of  bronchi,  869 

chancre  of,  839 

colloidal    gold    test    of    cerebrospinal 
fluid  in,  810 

course    of,    814 

diagnosis  of,  821 

duration  of,  815 

of  ear,  862 

effect   of   treatment  of,   820 

of   epididymis,   592,   880 

etiology  of,  802 

experimental,  805 

extragenital  infection  with,  795 

of  eye,  866 

fetal,  874 

of  heart,  872 

hereditary,    799,   873 
and  rachitis,   882 
and  tuberculosis,  882 
of  bones,  884 


Syphilis,  hereditary,   dystrophies  of,   883 

of  ear,  881,  886 

of  eye,  881,  886 

fetal,  874 

infantile,  876 

keratitis  of,   886 

late,  883 

of  liver,  881 

of  lung,   870,  881 

of  mucous  membranes,   879 

of   nails,    S78 

of  nervous  system,  881,  884 

of  nose,  876 

of  skin,  877 

of  spleen,   881 

stigmata  of,  884 

of  teeth,  885 

of  testicle,   880 

of  third  generation,  800 

treatment   of,   886 
hygiene  of,  837 
immunity  to,  806 
incubation  of,  815 

influence  of  salvarsan  upon  infectious- 
ness of,  799 
initial  lesion  of,  839 
of  intestines,  871 
of  joints,  869 
of  larynx,  853,  862 
of  liver,  870 
of  lungs,  869 

mercurial  treatment  of,  829 
mortality  from,  820 
of  mucous  membrane,   853,   862 
of  muscles,  869 
of  nasal  septum,  862,  876 
of  nervous  system,  865 

treatment  of,  826 
neurorecidiv  of,  828 
onset  of,  814 
of  palate,  861 
pathology  of,  810 
prevention    of,   823 
prognosis  of,  818 
prophylaxis   of,  805 
second   attack   of,   800 
secondary  lesions  of,  793,  816,  848 

of  mucous  membranes,  853 

of  skin,  848 
of  skin,   846,  877 
spinal  fluid  tests  for,  809 
of  stomach,  871 
tertiary  lesions  of,   794,   817 


INDEX 


905 


Syphilis,  of  testicle,  592,  880 
of  third  generation,  800 
of  trachea,  869 
transmission  of,  795 
treatment   of,   823 
effect  of,  820 
by  hygiene,  829,  837 
by  mercury,  829 
by  potassium   iodid,   837 
by  salvarsan,  826 
of  velum,  861 

Wassermann  reaction  for,  806 
of  cerebrospinal  fluid  in,  809 
Syphilitic  alopecia,  851 
Syphilitic  aneurysm,   872 
Syphilitic  arthritis,    869 
Syphilitic  atrophy  at  base  of  tongue,  855 
Syphilitic  chorioretinitis,  866 
Syphilitic  condyloma,    854 
Syphilitic    deafness,    862 
Sj-philitie    dystrophies,   883 
Syphilitic   glossitis,   860 
Syphilitic  gumma,   860 
Syphilitic  iritis,  866 
Syphilitic  leg   ulcer,    860 
Syphilitic  leukoplakia,  854 
Syphilitic  optic    neuritis,    866 
Syphilitic  pemphigus,  878 
Syphilitic  pneumonia,   870 
Syphilitic  sclerosis  of  tongue,  860 
Syphilitic   ulcer   of  bladder,   435 
Syphilitic  urethritis,   188 
Syringes,  25 
Systemic  gonorrhea,  121 

Tapping  of  hydrocele,  778 

Teeth,  hereditary  syphilis  of,   885 

Tenderness,  costovertebral,  3 

Teratoma  of  testicle,  594 

Tertiary  lesions  of  syphilis,  794,  817 

Tertiary  sj^hilids,   856 

Test,  acetic  acid,  15 

luetin,   808 

three-glass,  18 

two-glass,   17 
Testicle,  anatomy  of,  557 

anomalies  of,  561 

atrophy   of,   588 

contusion  of,  588 

descent  of,  560 

dislocation   of,  588 

ectopic,  561 

embryology  of,  560 


Testicle,  gangrene  of,  589 

hereditary  syphilis  of,  880 

hypertrophy   of,   588 

irritable,   590 

neoplasms  of,  594 

neuralgia  of,  590 

palpation  of,  9 

physiology  of,  559 

syphiUs  of,  592 

teratoma   of,   594 

tuberculosis  of,  582 

tumors  of,  594 

wounds   of,  589 
Third  generation,  hereditary  syphilis  of, 

800 
Thorium  nitrate  for  pyelography,  96 
Three-glass  test,   18 
Tongue,  gumma  of,   861 

leukoplakia   of,   854 

syphilitic   atrophy   at  base   of,   855 

syphilitic   sclerosis   of,   860 

of  urinary   toxemia,   344 
Torsion,  of  penis,  640 

of  spermatic  cord,   589 
Total    cystectomy,    722 
Toxemia,    syphilitic,    816 
Toxicology  of  mercury,  830 
Trabeculation   of   bladder,   367,   538 

cystoscopic    appearance    of,    64 
Trachea,  syphilis  of,   869 
Transmission,  of  gonorrhea,   118 

of  syphilis,  795 
Transperitoneal  incision  for  kidney,  686 
Traumatic  cystitis,  364 
Traumatic    hydronephrosis,    515 
Traumatic   orchitis,    577 
Traumatic   stricture,   254,   276 
Traumatic   ulcer  of  bladder,  435 
Traumatic  urethritis,  187 
Treponema  pallidum,  803 
Trigone,   37 

cystoscopic    appearance   of,   55 
Tripperfaeden,    198 

a  symptom  of  stricture,  260 
Tubercle   bacillus,   424 
Tubercular  syphilids,  856 
Tuberculosis,  and  hereditary  syphilis,  882 

of  bladder,  432 
cystoscopy  in,  60 

of  epididymis,   580 

genitourinary,  414 
of   kidney,   416 

of  penis,  648 


906 


INDEX 


Tuberculosis,  of  prostate,  436 

of  seminal  vesicle,  432,  438 

of  testicle,  582 

of  vas  deferens,  582 
Tumors,   of   bladder,  495 

suprapubic   section   for,   719 

of   kidney,  485 

nephrectomy  for,   698 

of  kidney  pelvis,  493 

of  penis,  652,  656 

of  prostate,  311 

prostatectomy  for,   749 

of  scrotum,  555 

of  seminal  vesicle,  620 

of  spermatic  cord,   614 

of  testicle,  594 

of  ureter,   493 

of  urethra,  509 
Tunica  albuginea,  558 
Tunica  vaginalis,  557 

calcification  of,  600 

hematocele  of,   608 

hydrocele  of,  598 

inflammation  of,  568 
Tunnel  entrance  of  ureter.     See  Ureter 
Two-glass  test,  17 
Typhoid  kidney  infection,  350 

Ulcer  of  bladder,  435 
Ulcerated  syphilids,  857 
Ultzmann  instillator,  25 
Upper   urinary  tract,   etiology  of   infec- 
tion of,   318 
Urachus  cyst,  543 
Urachus  fistula,  543 

Urea  estimation,  a  test  of  kidney  func- 
tion, 76 
Ureter,  abnormal  implantation  of,  536 

absence   of,    536 

anastomosis  of,  703 

anatomy  of,  451 

anomalies  of,  536 

calculi  of,  382 

carcinoma  of,  454 

cystoscopic   extraction  of,   760 
radiography   of,   90 

congenital  stricture  of,  537 

crossed,    536 

double,  536 

epithelioma  of,  454,  493 

fistula  of,  454 

operation  for,  763 

golf-hole,  61 


Ureter,  intravesical  cyst  of,  64,  537 

mouth,  appearance  of,  55,  60 

operations   upon,    700 

palpation   of,   5 

papilloma  of,  454 

physiology  of,  452 

plastic    operations    upon,    701 

reduplication  of,  536 

retraction  of,  61 

rupture  of,  ol8 

stricture  of,  453 

tumors  of,  493 

tunnel  entrance,  61 

wounds  of,  518 
Ureter  catheter,  50,  67 

in  diagnosis  of  kidney  tuberculosis,  425 

indwelling,   361,   362 

for  kidney  function  test,  85 

with  phenolsulphonephthalein,  82 

radiographic,  93 

wax-tipped,  394 
Ureter  catheterization,  67 
Ureteral   cysts,   453 
Ureteritis,   453 

Uretero-intestinal  anastomosis,   707 
Ureteroplasty,   702 
Ureteropyelostomy,  702 
Ureterostomy,  705 
Ureterotomy,  700 

for  stone,  700 
Ureterovesical  cyst,  537 

cystoscopic  appearance  of,  64 
Urethra,   anatomy   of,  32 

angioma  of,  509 

anomalies  of,  543 

anterior,   33 

antisepsis  of,  27 

atresia  of,  544 

bacteria  of,  166 

carcinoma  of,  510 

chancre  of,  188 

congenital  dilatation  of,  544 

congenital  stricture  of,  544 

crypt  of,  33 

curve  of,   38 

cysts  of,  510 

diameter  of,  37 

double,  543 

fibroma  of,  509 

foreign  bodies  in,  410 

glands  of,   33 

gonorrhea  of  female,  141 
of  male,  157 


INDEX 


907 


Urethra,  injection  of,  205 
instillation  of,  207 
irrigation  of,  25 
length  of,  37 
membranous,  34 
mobility  of,  40 
mucosa  of,  33 
neoplasms  of,  509 
palpation  of,  8,  9 
papilloma  of,  509 
physiology  of,  39 
posterior,  34 
prolapse  of  female,  545 
prostatic,   35 
resection   of,   734 
rupture   of,   525 
sarcoma  of,  510 
sensibility  of,  39 
Sinclair's  method  of  tying  catheter  in, 

675 
stricture  of,  251 
tumors  of,   509 
urethroscopy  of  anterior,  201 

of  posterior,  202 
wounds  of,  523 
Urethral  anesthesia,  51 
asepsis,  26 
calculus,  382,  411 
chancre,  188 
chill,  345 
cysts,  453 
false  passage,  262 
fistula,  265 

operation  for,  765    • 
glands,  33 
instruments,  19 

asepsis  of,  28 

curve  of,  39 

lubrication  of,  29 

passage  of,  41 
irrigation,   25 
neuroses,   181,  624 

treatment  of,  246 
papilloma,    187 
shock,  40 
sphincter,  36 

stricture.     See   Stricture  of  urethra 
Urethritis  ab  ingestis,  185 
bacteria-  of   chronic,    165 
diagnosis   of   gonorrheal,   191 
diathetic,  185 
eczematous,  188 
gonorrheal.     See  Gonorrheal  urethritis  | 


Urethritis   ab   ingestis,   gouty,   185 

herpetic,  188 

neoplastic,    187 

nongonorrheal,   185 

simple,  185 

syphilitic,  188 

traumatic,  187 
Urethroperineal  fistula,  265 

operation  for,  765 
Urethrorectal  fistula,  528 

operation  for,   764 
Urethrorrhea,  188 
Urethroscopes,  199 
Urethroscopy,   199 

for   carcinoma  of  prostate,  203 

of  posterior  urethra,  202 

in  prostatism,  203 

for  treatment,  203 
Urethrotomy,     external.       See     Perineal 
section 

internal,   730 
Uric  acid  stone,  377 
Urinalysis,   11 

clinical,  2,  14 
Urinary  calculus.     See  Calculus 
Urinary  fistula,  operations  for,  761 
Urinary  infiltration,  265 
Urinary  septicemia,  345 
Urinary  toxemia,  343 

in  prostatism,  295 
Urine,  comparison  of  first  with  second,  17 

incontinence  of,  466 
Urine  separators,  50 
Urotropin.     See  Hexamethylenamin 
Utricle,  35 

treatment  of  inflamed,  247 

Vaccine  treatment,  of  gonorrhea,  114 

of  renal  infection,  360 

of   urinary   septicemia,   362 
Vaginal  palpation  of  ureters,  6 
Vaginitis,   gonorrheal,   148 
Varicocele,   611 

'operation  for,  777 
Varicose  veins  of  bladder,  480 
Vas  deferens,  anatomy  of,  610 

palpation    of,    10 

tuberculosis  of,  582 
Vasotomy     (Belfield's    operation),    245, 

308,   776 
Velum,  syphilis  of,  861 
Venereal  warts,  653 
Verumontanitis,  162 


908 


INDEX 


Verumontanitis,   treatment  of,   247 
Verumontanum,  35 

urethroscopy  of,  203 
Vesical  calculus.     See  Bladder  stone 
Vesicle.     See  Seminal  vesicle 
Vesico-intestinal  fistula,  472 
Vesicouterine  fistula,  operation  for,  764 
Vesicovaginal   fistula,  operation  for,   763 
Vesiculectomy,   245,   751 
Vesiculitis.     See  Seminal  vesiculitis 
Vesiculotomy,  245,  751 
Virchow's    smooth    atrophy    at    base    of 

tongue,  855 
Volkmann's  operation  for  hydrocele,  780 
Vulvitis,  gonorrheal,  150 
Vulvovaginitis,  gonorrheal,  131 

Wassermann  reaction,  806 

of  cerebrospinal  fluid,  809 

provoked,   808 
Wax-tipped  catheter,  394 
Wilms 's  tumor  of  kidney,  487 


Winckelman's    operation    for    hydroc 

780 
Wintergreen  oil,  222 
Woman,  gonorrhea  in,  137 
Wounds,  of  bladder,  520 

of  kidney,  516 

of  penis,  641 

of  scrotum,  551 

of   seminal  vesicle,   618,   619 

of  spermatic  cord,  590 

of  testicle,  589 

of  ureter,  518 

of  urethra,  523 
Woven   catheters,  23 

X-ray.     See  Radiography 

Young's  prostatectomy,   739 
Young's  prostatic  punch,  309,  748 

Zinc  acetate,  213 
Zinc  sulphate,  213 


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